Gout and Nutrition

Question 1

What is gout?

Answer 1

A type of inflammatory arthritis that causes pain, discomfort and damage to joints

Question 2

What causes gout?

Answer 2

Deposition of monosodium urate crystals formed by excess uric acid. The crystals are formed from excess uric acid.

Question 3

What is uric acid?

Answer 3

Breakdown product of purine

Question 4

What are the risk factors for developing gout?

Answer 4

• Genetic predisposition
• Medicines that raise uric acid
• Obesity
• Weight gain
• Hypertension
• Dyslipidaemia
• Alcohol consumption

Question 5

Which drugs lead to raised uric acid levels?

Answer 5

• Aspirin
• Ciclosporin
• Cytotoxic medicines
• Diuretics
• Ethambutol
• Levodopa
• Pyreizinamide
• Ribavaran & Interferon
• Teriparatide

Question 6

What is the first line treatment for gout?

Answer 6

NSAIDs - start at high dose then taper 24 hours after resolution of attack

Question 7

Which drug can be used in gout patients when NSAIDs are contraindicated?

Answer 7

Colchicine

Question 8

How does Colchicine work?

Answer 8

Arrests assemble of microtubules in neutrophils and inhibits many cellular functions

Question 9

What are the side effects of colchicine?

Answer 9

• Abdominal cramps

- Nausea & vomiting

Question 10

When should colchine be used with caution?

Answer 10

In chronic heart failure patients - can constrict blood vessels and stimulate central vasomotor

Question 11

When would a corticosteroid be used in gout patients?

Answer 11

When NSAIDs and colchicine are contraindicated or ineffective

Question 12

Give examples of corticosteroids used in gout

Answer 12

• Methlypredinisolone acetate

- Triacinalone acetonide

Question 13

What the aim of gout prophylaxis?

Answer 13

Aim is to maintain serum uric acid levels below saturation point of monosodium urate - if serum rate is low then crystal deposits dissolves

Question 14

Which drugs can be used prophylactically in gout patients?

Answer 14

• Allopurinol
• Febuxostat
• Uricosuric medicines: Benzbromarone and Pegloticase

Question 15

How does allopurinol work?

Answer 15

Inhibits xanthine oxidase which reduces production of uric acid

Question 16

What does of allopurinol should be given to patients with normal renal function?

Answer 16

100mg daily and increase every 2/3 weeks till optimum serum levels are reached

Question 17

What does allopurinol interact with?

Answer 17

Azathioprine

Mercaptopurine

Question 18

Which patients is febuxostat indicated for?

Answer 18

Patients with chronic hyperuricaemia

Question 19

What are the potential ADRs associated with febuxostat?

Answer 19

• Respiratory infection
• Nausea
• Diarrhoea
• Headache
• Liver function abnormalities

Question 20

How do uricosuric medicines work?

Answer 20

Increase excretion of gout

Question 21

Give examples of uricosuric medicines

Answer 21

Sulphinpyrazone
Probenacid
Benzbromarone
Pegloticase

Question 22

Which lifestyle changes should be considered in gout patients?

Answer 22

• Moderate physical exercise
• Weight loss
• Purine intake shouldn’t exceed 200mg a day
• Avoid: shellfish, offal and sardines
• Reduce alcohol intake

Question 23

Why are vitamins and minerals required in the body?

Answer 23

They play a key role as co-factors or co-enzymes in mot metabolic reactions

Question 24

Give examples of water soluble vitamins

Answer 24

Vit C - ascorbic acid
Vit B1 - Thiamine 
Vit B2 - Riboflavin 
Vit B3 - Niacin / Nicotinic acid
Vit B5 - Pantothenic acid 
Vit B6 - Pyridoxine 
Vit B7 - Biotin 
Vit B9 - Folic acid 
Vit B12 - Cyanocobalamin

Question 25

Give examples of fat soluble vitamins

Answer 25

Vit A - retinol Vit D - Cholecalciferol Vit E - 𝜶 tocopherol Vit K - Phytomendione

Question 26

Where are water soluble vitamins absorbed?

Answer 26

In the duodenum

Question 27

Where are fat soluble vitamins absorbed?

Answer 27

In the ileum

Question 28

What absorbed Vit B12?

Answer 28

Intrisic factor in the ileum

Question 29

Apart from the diet, what is another source of Vit D?

Answer 29

Sunlight

Question 30

What does Vit A deficiency cause?

Answer 30

Poor night vision

Question 31

What does Vit B1 deficiency cause?

Answer 31

Wenies encephalopathy

Question 32

What does Vit B7 deficiency cause?

Answer 32

Hair loss | Anaemia

Question 33

What does Vit B9 deficiency cause?

Answer 33

Megaloblastic anaemia | Neural tube defects

Question 34

What does Vit B12 deficiency cause?

Answer 34

Pernicious anaemia | Peripheral neuropathy

Question 35

What does Vit C deficiency cause?

Answer 35

Painful joints | Scurvy

Question 36

What does Vit D deficiency cause?

Answer 36

Rickets | Osteoporosis

Question 37

What does Vit K deficiency cause?

Answer 37

Abnormal clotting

Question 38

What do folic acid supplements do in pregnancy?

Answer 38

Prevent neural tube defects - spina bifida

Question 39

What dose of folic acid should given to a woman with no previous history of neural tube defects?

Answer 39

400µm OD until 12th week

Question 40

When should a woman be given a dose of 5mg folic acid?

Answer 40

- Previous history of neural tube defects | - Epilepsy / on anti-epileptics

Question 41

What are minerals and trace elements required for?

Answer 41

- Formations of bones and teeth - Body fluids and tissues - Enzyme systems - Nerve function - Blood constituents

Question 42

Give examples of minerals

Answer 42

- Calcium - Magnesium - Phosphorous - Sodium - Potassium Required in large amounts

Question 43

Give examples of trace elements

Answer 43

``` Iron Zinc Iodine Fluoride Selenium Copper ```

Question 44

What does potassium and magnesium deficiency cause?

Answer 44

Cardiac arrhythmias

Question 45

What does calcium and magnesium deficiency cause?

Answer 45

Osteoporosis Muscle cramps Tetany

Question 46

What does zinc deficiency cause?

Answer 46

Hair loss | Poor wound healing

Question 47

What does iron deficiency cause?

Answer 47

Anaemia

Question 48

What does copper deficiency cause?

Answer 48

Wilson's disease

Question 49

What are the problems associated with supplements?

Answer 49

``` Toxicity / accumulation Supplements are expensive Complacency No control because of legal status Difficult to offer advice as they are not medicines ```

Question 50

What does folic acid interact with?

Answer 50

Methortrexate

Question 51

What does vitamin C interact with?

Answer 51

Iron

Question 52

What are the consequences of malnutrition?

Answer 52

- Weakness and loss of muscle mass - Apathy and depression - Reduced immune system - Poor wound healing - Increased morbidity and mortality

Question 53

What are the normal feeding aims?

Answer 53

Energy: 25-35 kcal / kg / day Protein: 0.8 - 1.5g / kg / day Fluid: 30 - 35ml / kg / day

Question 54

Which methods can be used to feed patients

Answer 54

- Normla diet - Enteral nutrient - IV fluids - Parenteral nutrition

Question 55

How is enteral nutrition administered?

Answer 55

Via GIT

Question 56

What are the benefits of EN?

Answer 56

- More physiological - Less risk of infection - Maintain GIT - Gut bacteria translocation - Lower cost - Easier for home patients - Patient ease - Calorie control

Question 57

Which patients would benefit from EN?

Answer 57

- Patients with eating / swallowing difficulties - Severe intestinal malabsorption - Increased nutritional requirements - Eating disorders - Self neglecting patients

Question 58

What are the routes of EN administration?

Answer 58

Oral Naso gastric tube Percutaneous endoscopic gastronomy (tube passed through abdominal wall) Percutaneous endoscopic jejunostomy

Question 59

What are the problems associated with EN?

Answer 59

- diarrhoea - regurgitation - abdominal distention - blocked feeding tube - problems with the pump - taste & acceptability - dislocation

Question 60

How should drugs be administered in EN patients?

Answer 60

- Use liquid preparation where possible - Give each drug separately - Flush with >20ml water before and after - Crushed tablets may block tube - Not MR or e/c

Question 61

Which drug directly interact with EN feed?

Answer 61

``` Ciprofloxacin Albumin antacids Theophylline Phenytoin Penicillamine ```

Question 62

When should TPN be used?

Answer 62

- When EN is not an option - When patient can't take food in orally - Digestion / absorption problems - Unavailable GIT

Question 63

What are short term indications for TPN?

Answer 63

- waiting for feeding tubes - bowel obstruction - excisional surgery - ICU patients with multi-organ system failure - severe pancreatitis - pre-term neonates - acute intestinal failure

Question 64

What are long term indications for TPN?

Answer 64

- radiation enteritis - Crohns disease - motility disorders - bowel infarction - cancer surgery - chronic intestinal failure

Question 65

How is short term TPN administered?

Answer 65

via Venflon

Question 66

How is long term TPN administered?

Answer 66

Peripherally inserted central catheter (PICC) Hickman line Central line : intrajugular, subclavian, femoral

Question 67

What needs to be monitored when a patient is on TPN?

Answer 67

``` Clinical history U&Es Glucose Vitamins LFTs FBS Trace elements Fluid balance Weight Line iste ```

Question 68

What are TPN complications?

Answer 68

- air embolism / insertion problems - catheter blockage - line infections - metabolic problems - bone disease - re-feeding syndrome

Question 69

What is re-feeding syndrome?

Answer 69

It is characterised by abnormalities in fluid balance, glucose metabolism, vitamin deficiency, hypophosphatemia, hypermagnesaemia and hypokalaemia

Question 70

How is re-feeding syndrome prevented?

Answer 70

By introducing feed at no more than 50% of the normal requirements. Start at 10kcal / kg / day and increase slowly to meet full needs by 4-7 days