Transcript Clinical Case 6

Clinical Case #6
By Chen , chun-Yu (Kim)
Chen , I -chun (Afra)

When he was 30 years old, a construction worker
developed redness and swelling of the instep of his right
foot without a recognized antecedent injury. The
affected area was intensely painful and tender. Hot soaks
were applied, and after 10 years he was able to return to
work.

During the following 2 years, he experienced
increasingly frequent episodes of intense inflammation of
joints of the feet. The swelling and pain persisted for
longer and longer periods of time. In one attack where
he developed a swelling on the back of his heel, he went
to his physician, who diagnosed gout and prescribed
high dose colchine.

His serum uric was 12 mg/dl and urate monohydrate
crystals were isolated from an ulcerated tophaceous
mass on his heel.
Gout Images:
1.what is the primary therapeutic
objective during an acute attack of
gouty arthritis?

Answer:
Arthritis is treated first and
hyperuricemia later。
2.Should immediate steps be taken to
lower serum uric acid ?Why or
why not ?

Answer:
no ,because sudden reduction often
precipitates further episodes of gouty
arthritis
3.What drugs can be used to prevent
a recurrence of gout until serum uric
acid levels are reduced ?
-NSAIDs:
 -Colchicine
 -corticosteroids
 -analgesics

4.Describe the actions of the 2 classes of
drugs available for the control of
hyperuricemia?

NSAIDs and Uricosuric drugs
– NSAIDs
 Reduce inflammation caused by leukocytic reactions to
the deposition of uric acid crystals.
 NSAIDs block prostaglandins, the substance that dilates
blood vessels and causes inflammation and pain of gout.
– Uricosuric drugs
 Inhibit the reabsorption of uric acid by a weak acid
carrier mechanism at the proximal part of nephron
 Work by helping the kidneys get rid of the excess uric
acid produced in the body.
5.What factors determine which of these
drug to use for treatment?

In acute gout attacks NSAIDs, colchicine, and
corticosteroids are considered for use. In chronic
gout attacks the anti-metabolite (allopurinol) and
uricosuric drugs are considered.
– Acute gout:
 NSAIDs are the preferred medication for gout
– Side effects
 Upset stomach
 Bleeding
 Kidney damage
 High potassium levels
 Retention of sodium and potassium
5.What factors determine which of these drug
to use for treatment?(cont.)
 Colchicine is very effective, but the side effects can be intolerable by
many patients.
– These side effects include:
 Diarrhea
 Vomiting
 Nausea
 Abdominal pain
 Cramps
 Suppression of blood cell production in the bone marrow.
 Corticosteroids aren’t as effective as NSAIDs or colchicine
– Side effects:
 Retention of sodium with swelling
 High blood pressure
 Pain
 Discomfort
 Joint damage if over used
5.What factors determine which of these drug
to use for treatment?(cont.)
– Chronic Gout:
 Allopurinol
– Action
 Inhibit Xanthine oxidase
 Prevents the formation of uric acid
– Side effects
 Upset stomach
 Skin rash
 Decrease in number of white blood cells
 Liver or kidney damage
 Inflammation of blood vessels (vasculitis)
 Uricosuric drugs
– Action
 Promote excretion of uric acid
– Probenicid & Sulfinpyrazone, Side effects




Headache
Nausea
Vomiting
Kidney stones
6.Should this patient be told to avoid
alcohol? Why or why not?
Yes, the patient should avoid certain
types of alcohol such as beer ,because it
contains high contents of purine. There
seems to be a link between incidence of
gout and alcohol intake.
7.What analgesic would you tell the patient
to avoid for treatment of a headache?
Why?

Aspirin should be avoided, because at
low doses which is what is recommended
for headaches aspirin causes formation of
urate. In order for Aspirin to be used as a
uricosuric drug it has to have elevated
doses.
– Low dose
 1-2 gm/day
 Decrease rate of urate excretion and elevate
plasma urate concentration.
7.What analgesic would you tell the patient
to avoid for treatment of a headache?
Why?(cont.)
– Intermediate dose
 2-3 gm/day
 Does not alter urate excretion
– Large dose
 >5 gm/day
– Uricosuric and lowers plasma urate levels