Presentation - Uric Acid

PMtech Polymer Technology Sdn. Bhd. - Staff Training

Uric Acid and Gout


What is Uric acid?

• Breakdown product of purine bases (part of the body genetic material)

• Excreted in the urine and to lesser extend the intestinal tract

• Concentrations in the blood related to balance between production and excretion


High purine foods

• Shellfish – “lala”, oysters, kerang

• Organs – intestines, kidneys , liver, heart

• Seafoods – sardine, ikan bilis

• Beans – soyabean, peas

• Vegetables – spinach


Serum Uric Acid LevelsAdults (Young)

Males : 2.0 - 7.5 mg/dL (0.12 - 0.44 mmol/L)

Females : 2.0 - 6.5 mg/dL (0.12 - 0.38 mmol/L)(levels fall in early pregnancy)

Older than 40

Males : 2.0 - 8.5 mg/dL (0.12 - 0.50 mmol/L)

Females : 2.0 - 8.0 mg/dL (0.12 - 0.47 mmol/L)

Supersaturated at > 7.0 mg/dL (>0.41 mmol/L)


Measurement of Uric Acid

Blood – Patient should be fasting– Evaluate the blood levels of uric acid

and for goutUrine

– Collect 24 hour urine– Uric acid levels in the urine for kidney

stones


Greater than normal values

• Acidosis• Alcoholism• Hypothyroidism• Lead poisoning• Leukemia• Nephrolithiasis• Polycythemia vera

• Renal failure• Toxemia of pregnancy• Purine rich diet• Severe exercise• Trauma• Diabetes mellitus• Gout


Lower than normal values

– Fanconi’s syndrome– Wilson’s disease– Low purine diet


Gout

• Caused by an excess of uric acid in the body– increased production of uric acid– decrease in the elimination of uric acid

• Long term– Deposits around joints forming needle like

crystals– Under the skin as tophi– In the urinary tract as stones


Impact of Gout

• Incidence : 5 - 8.5 / 1000 individuals

• 4 x as many men as women

• Occurs at a younger age in men

• Associated with obesity, hypertension, hyperlipidemia and diabetes


Association of Uric acid level and Gout

Serum acid levelsmg/dL (mmol/L)

Incidence of Gout (%)

>9.0 mg/dL(>0.52 mmol/L)

7.0 – 8.0

7.0 – 8.9 mg/dL(0.41 – 0.52 mmol/L)

0.5 – 3.7

< 7 mg/dL(<0.41 mmol/L)

0.1

>10 mg/dL (>0.59 mmol/L) : Chance of an acute attack is >90%


Four stages of Gout

• Asymptomatic

• Acute attacks

• Intercritical

• Chronic


Symptoms of Gout

• Joint Pain– Begins suddenly

– One or more joints involved (pain in the hip, knee, ankle, foot, shoulder, elbow, wrist, hand, or other joints)

– Most often affected : Great toe, knee or ankle joint)

• Swelling of the joints• Stiffness of the joints• Fever may be present• Skin lumps


The Big Toe


Precipitating factors of Gout• Trauma (even minor)• Overindulgence in purine

rich foods• Alcohol• Surgery• Fatigue• Emotional stress• Medical stress


Diagnosis of Gout• History and physical examination• Elevated serum uric acid (> 7 mg/dL or

0.41 mmol/L)– Note : About 30% have normal levels during an

acute attack)

• Demonstration of needle shaped urate crystals (Monosodium urate - MSU ) in the tissue and/or synovial fluid


X-Ray of the Hand


MSU Crystals


Prognosis of Gout

• Current therapy permits normal life

• For advanced stages, tophi can be resolved, joint function improved and renal dysfunction arrested

• About 20% of patients with gout develop urolithiasis with uric acid or calcium oxalate stones


Tophi of the ear


The Hands


X-Ray of feet


Bladder Calculi


Treatment of Gout

• Objectives– Terminate acute attacks– Prevent recurrent attacks– Prevent further deposition of MSU and

resolution of existing tophi


Treatment of Acute Gout attacks• Medication

– Colchicine– NSAIDs– Aspiration of joints and steroid

injections

• General– Rest– Plenty of fluids– Splinting the joints


Treatment of Chronic Gout

• Colchicine

• Drugs to lower uric acid levels – prevent progressive joint damage– Resolution of tophi


Urate lowering drugs

• Uricosuric agents– Decrease readsorption of uric acid– Sulfinpyrazone and Probenecid

• Decrease production of uric acid– Allopurinol

• Inhibits uric acid synthesis

• especially useful in patients with kidney stones or severe renal dysfunction


Monitoring Uric Acid levels

• All patients with a history of hyperuricaemia and/or gout should have their uric acid levels monitored regularly

• Particularly important for patients on urate lowering agents for resolution of tophi


Resolution of tophi

• Takes months or even years

• Requires maintenance of serum uric acid levels < 4.5 mg/dL (0.26 mmol/L)

• Patients should have their uric acid levels monitored to achieve this


Who should be tested for uric acid levels?

Hyperuricaemia is associated with :• Obesity• Hypertension• Hyperlipidemia• Diabetes


Follow up of asymptomatic hyperuricaemia

• Therapy is not warranted for asymptomatic hyperuricaemia

• Detecting hyperuricaemia allows for an opportunity to modify or correct underlying cause

• Such individuals should be monitored regularly


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Presentation - Uric Acid