Uric Acid and Gout

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 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

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 High purine foods
• Shellfish – “lala”, oysters, kerang
• Organs – intestines, kidneys , liver, heart
• Seafoods – sardine, ikan bilis
• Beans – soyabean, peas
• Vegetables – spinach

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 Serum Uric Acid Levels
Adults (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)
PMtech Polymer Technology Sdn. Bhd. - Staff Training
Measurement of Uric Acid
Blood
– Patient should be fasting
– Evaluate the blood levels of uric acid
and for gout
Urine
– Collect 24 hour urine
– Uric acid levels in the urine for kidney
stones

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 Greater than normal values
• Acidosis • Renal failure
• Alcoholism • Toxemia of pregnancy
• Hypothyroidism • Purine rich diet
• Lead poisoning • Severe exercise
• Leukemia • Trauma
• Nephrolithiasis • Diabetes mellitus
• Polycythemia vera • Gout

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Lower than normal values
– Fanconi’s syndrome
– Wilson’s disease
– Low purine diet

PMtech Polymer Technology Sdn. Bhd. - Staff Training

 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

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 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

PMtech Polymer Technology Sdn. Bhd. - Staff Training

 Association of Uric acid level
and Gout
Serum acid levels Incidence of Gout (%)
mg/dL (mmol/L)
>9.0 mg/dL 7.0 – 8.0
(>0.52 mmol/L)
7.0 – 8.9 mg/dL 0.5 – 3.7
(0.41 – 0.52 mmol/L)
< 7 mg/dL 0.1
(<0.41 mmol/L)

>10 mg/dL (>0.59 mmol/L) : Chance of an

acute attack is >90%
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Four stages of Gout
• Asymptomatic
• Acute attacks
• Intercritical
• Chronic

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 Symptoms of Gout
• Joint Pain • Swelling of the joints
– Begins suddenly • Stiffness of the joints
– One or more joints • Fever may be present
involved (pain in the
hip, knee, ankle, foot, • Skin lumps
shoulder, elbow, wrist,
hand, or other joints)
– Most often affected :
Great toe, knee or ankle
joint)

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 The Big Toe

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Precipitating factors of Gout
• Trauma (even minor)
• Overindulgence in purine
rich foods
• Alcohol
• Surgery
• Fatigue
• Emotional stress
• Medical stress

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 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

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X-Ray of the Hand

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 MSU Crystals

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 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

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 Tophi of the ear

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 The Hands

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 X-Ray of feet

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 Bladder Calculi

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 Treatment of Gout
• Objectives
– Terminate acute attacks
– Prevent recurrent attacks
– Prevent further deposition of MSU and
resolution of existing tophi

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Treatment of Acute Gout attacks
• Medication
– Colchicine
– NSAIDs
– Aspiration of joints and steroid
injections
• General
– Rest
– Plenty of fluids
– Splinting the joints

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Treatment of Chronic Gout
• Colchicine
• Drugs to lower uric acid levels
– prevent progressive joint damage
– Resolution of tophi

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 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

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 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

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 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

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Who should be tested for uric
acid levels?
Hyperuricaemia is associated with :
• Obesity
• Hypertension
• Hyperlipidemia
• Diabetes

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 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

PMtech Polymer Technology Sdn. Bhd. - Staff Training

PMtech Polymer Technology Sdn. Bhd. - Staff Training