Gout

Gout Notes

1 of 4 GOUT

1. GOUT a. Gouty arthritis results from deposits of uric acid crystals in joints. b. The joint most often affected is the first MP joint (big toe) – other areas are ankle, knee, wrists, fingers, elbows c. Acute attacks are characterized by: 1. severe pain 2. swelling 3. erythema of the joint d. Prevalence: 1.6 – 13.6/1000 e. Increases with age f. Increases with body mass – the heavier the person, the more likely they’ll have gout g. More common in males than females h. Hyperuricemia 1. over secretion of uric acid 2. decreased excretion of uric acid or 3. Both i. Hyperuricemia = serum uric acid >7mg/dL – the amount of uric acid in the blood - (3-7 is normal) j. It’s either OVERPRODUCTION OR UNDEREXCRETION of uric acid – either you are producing too much and you can’t pee it out fast enough, or your kidneys are not working properly, and you can’t pee enough out. 2. WHAT TYPE OF DISEASE IS GOUT? a. Genetic b. Metabolic - ↑ uric acid in the blood c. Chemical/physical d. Inflammatory e. Rheumatic/Arthritic 3. PRIMARY HYPERURICEMIA a. ↑ urate levels or urate deposits appear to be due to faulty uric acid metabolism b. Maybe due to: 1. heredity 2. Starvation or severe dieting 3. High purine foods (organ meats, shellfish) 4. SECONDARY HYPERURICEMIA a. Clinical feature secondary to conditions that increase cell turnover and cell breakdown 1. Leukemia 2. multiple myeloma 3. some anemias (sickle cell) 4. psoriasis 5. ALTERED RENAL TUBULAR EXCRETION (uric acid underexcretion) due to: a. Side effects of some diuretics b. Low-dose salicylates c. Ethanol d. Chronic renal disease 6. S&S 1. Hyperuricemia 2. Acute gouty arthritis – when crytals go to a joint – inflammation 3. Tophi – accumulations of sodium urate crystals due to repeated attacks of gout – they are deposited in: a. great toe b. hands c. ear 4. Gouty nephropathy – renal impairment 5. Uric acid urinary calculi – kidney stones

Gout Notes

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7. 4 STAGES OF GOUT a. Asymptomatic Hyperuricemia 1. may be hyperuricemia, but never progress to gout 2. just their blood level is >7 – but no S&S b. Acute Gouty Arthritis 1. this is where the body’s immune system attacks and treats the crystals as foreign substances–inflammation 2. this is the most common stage 3. big toe most common place 4. Triggered by a. alcohol b. trauma c. diet – organ meats, shrimp d. medications – low dose of salicylates e. surgical stress – may have to increase their medication a few days before surgery f. illness 5. Abrupt onset often occurs @ night – the patient awakes w/severe pain, redness, swelling, warmth of affected joint 6. this will start in 1-3 days if not treated 7. will subside spontaneously over 3-10 days even without treatment 8. attack is followed by symptom free period – Intercritical Stage c. Intercritical Gout 1. Stage remission 2. could be 3-40 years without episodes 3. if treated though, may not progress at all 4. with time, however, attacks tend to occur more frequently, involve more joints, and last longer d. Chronic Tophaceous Gout 1. this is the chronic stage 2. Tophi are generally associated w/more frequent and severe inflammatory attacks 3. Tophi may be found in: a. Achilles tendons b. forearms c. Aortic walls d. heart valves e. nasal and ear cartilage f. eyelids g. cornea h. sclerae 4. Joint enlargement may cause loss of joint motion 5. Uric acid deposits may cause renal stones & kidney damage 8. TOPHI a. uric acid crystals deposit in subcutaneous tissue over time resulting in the formation of small, white nodules called tophi. b. Tophi are diagnostic of chronic gout. c. Found 1. helix of the ear 2. fingers 3. hands 4. knees 5. feet d. may have to open and drain these lesions 9. Uric Acid Kidney Stones a. Kidney stones are more prevalent in patients with gout than the general population. b. Renal stones can cause obstruction, dilation, and atrophy of proximal tubules and lead to acute renal failure. c. Stones deposited in renal interstitial tissue can lead to chronic renal failure. 10. MEDICAL MANAGEMENT – Only after the acute inflammation has subsided!!! a. DX- microscopic examination of the synovial fluid from the affected joint.- Uric acid crystals can be seen within neutrophils that have ingested the crystals (phagocytosis). b. Management of hyperuricemia, tophi, joint destruction and renal disorders is initiated after the acute inflammation subsides

Gout Notes c. Meds Drug/Class colchicine Antigout probenecid (Benemid) Antigout Uricosuric Agent allopurinol (Zyloprim) Antigout Xanthine Exidase Inhibitor

indomethacin (Indocin) Antirheumatic, NSAID prednisone Intermediate Acting Corticosteroid

3 of 4 Action

Nursing Implications

Lowers deposition of uric acid Interferes with WBC, reducing inflammation Does Not Alter Uric Acid Levels Increases urinary excretion of uric acid. Prevents tophi formation

Administer when attack begins. Increase dosage q hour until pain is relieved or diarrhea begins. Causes GI upset in most patients Be alert for nausea, rash, and constipation. So if it ↑ urinary excretion, you can’t give this to someone who has renal insufficiency or renal failure!! Maintain adequate fluid intake (2500 – 3000 ml/day) to minimize risk of renal stones. Good to give renal insufficiency patients or renal failure patients!! Monitor blood sugar in patients receiving oral hypoglycemic agents. S/E: bone marrow depression, vomiting, abdominal pain Report sore throat, fever, rash, swelling of ankles or fingers, tarry stools.

Interrupts the breakdown of purines before uric acid is formed. Blocks uric acid production.

Inhibits prostaglandin synthesis; exact mechanism of action is not known Initiates complex reactions responsible for antiinflammatory and immunosuppressive effects

Administer once-a-day doses at 9 AM to mimic peak corticosteroid blood levels. Taper doses when discontinuing long-term therapy. Given on short-term basis only!

d. Colchicine & NSAIDS (indomethacin, Indocin) = good to relieve ACUTE attacks e. Management of hyperuricemia, tophi, joint destruction, & renal disorders = give meds after the acute attack has subsided 11. NURSING MANAGEMENT a. Restrict high purine foods – organ meats b. Limit alcohol intake c. Maintain normal body weight d. Begin treatment early for acute attacks e. Pain management – during acute episodes of gouty arthritis f. During Intercritical period – Be aware that patients feels well and may abandon preventive behaviors, which may result in an acute attack g. Acute attacks are most effectively treated if therapy is begun early in the course h. Drink lots of fluid – unless the patient has renal problems, then they can’t drink lots of fluid 12. NSG DX a. Pain related to physical, biological, or chemical agents. – during attack b. Mobility impairment related to pain or discomfort c. Activity intolerance related to immobility d. Knowledge deficit related to lack of exposure – after attack is over e. Nutrition alteration: More than body requirements related to excessive intake f. Self-care deficit related to musculoskeletal impairment 13. NURSING INTERVENTIONS a. Observe pts. Functional ability daily; document and report changes b. Encourage pt. to verbalize pain & discomfort. Observe for non-verbal cues. c. Perform prescribed treatments d. Perform supportive measures as indicated e. Administer Pain meds f. Promote progressive mobilization within limits of patient’s tolerance for pain. g. Patient Teaching Plan

Gout Notes

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What is Gout? Cause & Symptoms Review patient specific causes Review stages & manifestations Triggers Medications to Prevent Attacks Stress importance of continuing medication even if symptoms are not present