Diagnosis, causes, clinical manifestations, management of hyperuricemia and Gout

1. HYPERURECEMIA
BY DR. JEHAD
ALADWANI

3. HYPERURECEMIA
 URIC ACID : END PRODUCT OF PURINE METABOLISM.
 HYPERURICEMIA: (SERUM URIC ACID LEVEL > 6.8 MG/DL [>
404.5 MCMOL/L]).
 1 MG/DL =59.5 MCMOL/L.
INTRODUCTION

4. CAUSES OF HYPERURICEMIA

5. HYPERURECEMIA
Causes Of Hyperuricemia
Overproduction
Underexcretion
Both Overproduction and Underexcretion
Metabolic States

6. HYPERURECEMIA
Causes Of Hyperuricemia Overproduction
 Hemolytic anemia
 Sickle cell disease
 Polycythemia vera
 Megaloblastic anemia
 Thalassemia
 Myelodysplastic
syndrome
 Leukemia
 Mitochondrial
myopathies
 Lymphoma
 Multiple myeloma
 Waldenström’s
macroglobulinemia
 Essential thrombocytosis
 Solid tumors
 Tumor lysis syndrome
 Psoriasis
 Sarcoidosis
 Idiopathic

7. HYPERURECEMIA
Causes Of Hyperuricemia
Underexcretion
Renal insufficiency
Dehydration/volume depletion
Lactic acidosis
Ketoacidosis
Drug-induced (eg, thiazides, low-dose
aspirin, cyclosporine, pyrazinamide,
ethambutol, levodopa)

8. HYPERURECEMIA
Causes Of Hyperuricemia Mixed
 Myocardial infarction
 Congestive heart failure
 Sepsis

9. HYPERURECEMIA
Causes Of Hyperuricemia Metabolic
states
 Hyperthyroidism
 Hypothyroidism
 Hyperparathyroidism
 Hypoparathyroidism
 Obesity

10. HYPERURECEMIA
• CONDITIONS ASSOCIATED WITH HYPERURICEMIA
 OBESITY
 HYPERTRIGLYCERIDEMIA
 GLUCOSE INTOLERANCE
 METABOLIC SYNDROME,
 HYPERTENSION
 ATHEROSCLEROSIS
 HYPOTHYROIDISM
 RENAL INSUFFICIENCY

11. HYPERURECEMIA
High-purine foods
 All meats, including organ meats
 seafood
 Meat extracts and gravies
 Yeast and yeast extracts
 beer, and other alcoholic beverages
 Beans
 Peas
 Lentils
 Oatmeal
 Spinach
 Asparagus
 cauliflower
 mushrooms
‫اللحوم‬ ‫جميع‬
‫االعضاء‬ ‫لحوم‬ ‫ذلك‬ ‫في‬ ‫بما‬
‫البحرية‬ ‫المأكوالت‬
‫والمرق‬ ‫اللحوم‬ ‫خالصات‬
‫الخميرة‬
‫والبيرة‬
‫األخرى‬ ‫الكحولية‬ ‫والمشروبات‬
‫الفاصوليا‬
‫والبازالء‬
‫والعدس‬
‫الشوفان‬ ‫ودقيق‬
‫والسبانخ‬
‫والهليون‬
‫والفطر‬ ‫القرنبيط‬

12. CLINICAL FEATURES

13. HYPERURECEMIA
CLINICAL PRESENTATIONS
GOUT
Asymptomatic hyperuricemia
Acute Gouty arthritis
Interval Gout
Advanced gouty arthritis
KIDDNEY
Uric Acid Calculi
Nephropathy

14. HYPERURECEMIA
Asymptomatic hyperuricemia
No Arthritis
No Renal Stones
2% Dvelop gout per 5 yrs if
sUA>475 mcmol/dl

15. HYPERURECEMIA
Acute Gouty arthritis
 More common in men (90%) than
in women
 Usually over 30 years of age
In women, the onset is typically
postmenopausal

16. HYPERURECEMIA
Acute Gouty arthritis
 Marked tenderness and swelling
of affected joint
ute onset with maximum pain in 4-12 hr
Recurrent pattern of similar attacks
Resolution of symptoms within 3-14 days
10% to 15% of attacks are polyarticular (asymmetric)

17. HYPERURECEMIA
Acute Gouty arthritis
 The MTP joint of the great toe
(“podagra”) 50%.
Hips and shoulders are rarely affected
oints of the feet, ankles, and knees,
are commonly affected
 Fever and may reach 39 C

18. HYPERURECEMIA
Acute Gouty arthritis
Gout
Triggers
Sudden decrease/increase in UA (allopurinol use)
Foods high in purines,Drinking sweet sodas
Dehydration
Drugs
Surgery or sudden, severe illness ,Infection
Joint injury

19. HYPERURECEMIA
Acute Gouty arthritis
Laboratory
Findings
Identification of sodium urate crystals in joint
fluid or material aspirated from a tophus
establishes the diagnosis
Single uric acid determination during an
acute flare of gout is normal in up to 25% of
cases
Serial measurements of the serum uric acid
detect hyperuricemia in 95% of patients

20. HYPERURECEMIA
Acute Gouty arthritis
Laboratory
Findings
Elevated WBC
Elevated ESR
Elevated CRP

21. HYPERURECEMIA
Interval Gout
Recurrent attacks separated by periods
• early attacks may last several months or up to several
years mean duration of 11 months
As the disease progresses ,acute attacks
occur with increasing frequency .
• period becomes progressively shorter  chronic
arthritis.

22. HYPERURECEMIA
Advanced gouty arthritis
Polyarticular Destroying form of arthritis
Affects hands, feet symmetrically
Subcutaneous tophus is characteristic
Most commonly in the fingers, wrists, ears, knees
Forearm, Achilles tendon and anywhere in the body

23. HYPERURECEMIA
Advanced gouty arthritis

24. HYPERURECEMIA
Advanced gouty arthritis

25. HYPERURECEMIA
Uric Acid Calculi
Present in 5–10% of patients with gouty arthritis,
50% UA stones have gout.
Manifest as renal colic or silent renal stone.
Urinary pH is consistently < 5.5
Increased uric acid > 800 MG per 24-hour urine

26. HYPERURECEMIA
Uric Acid Calculi
A plain abdominal radiograph (KUB) radiolucent
Renal US: detects renal calculi
CT: a very accurate method of diagnosing renal
and ureteric stones
HU (< 450) are typically composed of uric acid
(stone density on CT

27. HYPERURECEMIA MANAGEMENT

28. HYPERURECEMIA
Renal colic Management
NSAIDs (such as ibuprofen 600 mg
orally three times /day)
Alpha-blockers (such as tamsulosin,
0.4 mg orally once daily)
With or without prednisone 10 mg
orally daily for 3–5 days

29. HYPERURECEMIA
Uric Acid Stones Mangement
Hydration (Urine output 2 L / day )
Urine alkalinization (urinary pH > 6.2 and < 6.5 )
stone dissolve
Potassium citrate 30–60mEq day equivalent to 15–
30mL of a potassium citrate solution tds or qds with
full glass of water

30. HYPERURECEMIA
Uric Acid Stones Management
Or sodium bicarbonate
650mg tds or qds
allopurinol 300–600mg/day
(prophylaxis of recurrence)

31. HYPERURECEMIA
Management asymptomatic HU
Search and treat the cause
Most patients with asymptomatic
hyperuricemia never develop gout or stones.
Treatment is not recommended

32. HYPERURECEMIA
Acute Gouty arthritis Management
1-NSAIDs for 7-10/day course or 3-4 days after all
signs of inflammation have resolved
2- Colchicine
Severe cases (NSAIDs + Colchicine(
loading dose of 1.2 mg
followed by a dose of 0.6 mg 1 hour later and then
dosing for prophylaxis (0.6 mg once or twice daily)

33. HYPERURECEMIA
Acute Gouty arthritis Manegment
prednisone (40–60 mg/d) for 5–10 days(NSAIDs
and colchicine are contraindicated or severe )
Intraarticular administration of the
corticosteroid
Do not give uric acid lowering medications

34. HYPERURECEMIA
Interval Gout Management
Search and treat the cause
Diet : avoid purine rich foods.
Avoidance of hyperuricemic medications
Prophylaxis (UA lowering drugs)

35. HYPERURECEMIA
UA lowering drugs indications
Recurrent attacks >= 2 /year
Presence of tophi.
UA Renal Stones

36. HYPERURECEMIA
UA lowering drugs indications
Gouty arthritis
Not indicated in asymptomatic
hyperurecemia
First attack is controversial

37. HYPERURECEMIA
How to Use UA lowering drugs
The duration of treatment is indefinite
once indicated
Start 2-3 mo after the acute attack has
resolved
Start with low dose (allopurinol 100
mg/day)

38. HYPERURECEMIA
How to Use UA lowering drugs
Should always used with Colchicine w/wo NSAIDs until uric
acid target achieved
increased by 50-100 mg every 2-5 weeks until the target
serum uric
acid level is achieved
at or below 357 mcmol/L (or in some cases less 297.4
mcmol/L)

39. HYPERURECEMIA
UA lowering drugs
Xanthine oxidase inhibitors
Allopurinol Febuxostat
40 -80 mg /day max 120
mg
100 -300 mg /day max 800
mg

40. HYPERURECEMIA
UA lowering drugs
Uricosuric drugs
Probenecid Sulfinpyrazone
100 mg tid or qid0.5-1 g /day

41. HYPERURECEMIA
UA lowering drugs
Uricase
Pegloticase
8 mg every 2
Weeks IV

42. THANKYOU