Urology Case No 8. Serum Uric Acid

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Urology Case No 8. Serum Uric Acid

Serum_Uric_Acid

বিভিন্ন পরীক্ষায় সেরাম ইউরিক এসিড টেস্ট করা হয়,

আপনি জানেন? serum Uric acid বিষয় টা আসলে কি? কেনো এই টেস্ট করা হয়?

let us know with clear concept —

ছোট বেলায় বায়োকেমিস্ট্রি তে DNA/RNA এর স্ট্রাকচার পড়েছেন, তাইনা!

DNA/RNA এর স্ট্রাকচারে একটা বিষয় আছে Nitrogenous base, যাতে থাকে পিউরিন এন্ড পাইরিমিডিন.

আমাদের আলোচনা এই পিউরিন নিয়ে…

পিউরিন এক প্রকার প্রোটিন, এই প্রোটিন যে শুধু DNA তে পাওয়া যায়, বিষয় টা তা না,,,,,

এই প্রোটিন বিভিন্ন খাবারেও পাওয়া যায়, যেমন কলিজা, গোস্ত, মাছা৷ শীম, ছোলা ইত্যাদি,

পিউরিন Molecules ভেংগে সর্বশেষ যেই metabolic waste তৈরি হয়, সেটাই হচ্ছে Uric acid.

তাহলে চিন্তা করুন তো,

what is uric acid??

এইটা হচ্ছে পিউরিন ভেংগে তৈরি হওয়া এক প্রকার বর্জ্য পদার্থ,

শরীরের বর্জ্য পদার্থ শরীর থেকে ইউরিনের মাধ্যমে বের হয় যায়, বের হতে না পারলে শরীরের বিভিন্ন জায়গায় ডিপোজিশন হয়.

তার মানে কি দাড়ালো–

uric acid এর একটা certain level Blood এ থাকবে৷ আর বাকি সব ইইরিনের সাথে বের হয়ে যাবে.

এখন যদি Blood এ Uric acid এর পরিমান বেড়ে যায়, তাহলে বুঝতে হবে, kidney not functioning well…

বুঝলাম, কিডনি ভালো ভাবে কাজ করতেছেনা, তো সমস্যা কি,,,

হা সমস্যা আছে–

ইউরিক এসিড শরীর থেকে যদি ইউরিনের মাধ্যমে বের হতে না পারে

তাহলে তা পায়ে গিয়ে Deposition হবে, এবং Gout তৈরি করবে,,

ureter এ গিয়ে ureteric Stone তৈরি করবে,

সেইজন্য suspected gout patient, suspected, ureteric colic patient দের কে serum uric acid test করতে দেওয়া হয়

Hyperurecemia:: Uric acid এর নরমাল ভ্যালু হচ্ছে

2.6- 6 mg/dl

যদি এর চেয়ে বেড়ে যায়, তাহলে এই কন্ডিশক কে Hyperurecemia বলে

Gout, renal colic, এইসব পেশেন্ট দের হাইপার ইউরেসিমিয়া থাকতে পারে..

যেসব কারণে Hyperurecemia হয়,

genetics,

insulin resistance, hypertension,

hypothyroidism,

chronic kidney disease, o

besity, diet,

iron overload, use of diuretic..

চিকিৎসা — পিউরিন সমৃদ্ধ খাবার কমিয়ে দিন- সাথে ইউরিক এসিড তৈরি বন্ধ করে দিন-

খেয়াল করুন-Hypoxanthine থেকে Xanthine>> আর Xanthine Oxidase enzyme এর প্রভাবে >Uric acid

এখন Xanthine Oxydase এনজাইম কে inhibit করে দিলেই কিচ্ছা খতম…

Xanthine oxidase inhibitors –

1..Allopurinol 100 mg BD

2.. Febixostat 40 mg BD

4 weeks, if not decrease, double the dose.

★★ Allopurinol and Febuxostat দুইটা মেডিসিন এর নাম সবাই জানি-

Hypoxanthine হচ্ছে এক প্রকার পিউরিন,,, এইটা থেকে Xanthine Oxidase enzyme এর প্রভাবে uric acid তৈরি হয়,

ইউরিক অ্যাসিড bones এ জমে Gout তৈরি করে

Allopurinol and Febuxostat কি করে?

এইগুলি Hypoxanthine থেকে Uric acid তৈরি বন্ধ করে দেয়.

তাই এই দুইটা মেডিসিন Gout এ ব্যবহার হয়….

এখন জানা দরকার,

Allopurinol and Febuxostat এর মধ্যে প্রার্থক্য কি?

কখন allopurinol দিবেন?

কাকে Febuxostat দিবেন?

একজন healthy individual এর Uric acid এর নরমাল value upto 6 mg/dl

6 mg/dl এর উপরে গেলে বলে Hyperurecemia,

এখন Hyperurecemia হলেই কি Allopurinol /Febuxostat দিতে হবে?

Allopurinol and Febuxostat = দুইটাই Xanthine oxidoreductase inhibitors….

এই ২ টাই Serum uric acid কমায়,

Urice above 7.5 mg/dl হলে Gout and Renal stone /ureteric stone এর ঝুঁকি বাড়ে…

তবে কেবল ইউরিক এসিড বাড়লেই এইগুলি দেওয়ার দরকার নাই, যদি না Gout or uric acid stone না হয়।

কখন Allopurinol আর কখন Febuxostat?

যাদের Hyperurecemia +gout আছে, তাদেরকে Allopurinol /Febuxostat দিবে

allopurinol : FDA approval 1966

Febuxostat : FDA approval 2009

allopurinol হবে সব সময় Drug of choice. বা First line Treatment

Allopurinol এ কাজ না হলে তথা ৩-৬ মাস চলার পরে Uric acid Below 6 mg/dl না আসলে Switch to Febuxostat,,

Allopurinol থেকে Febuxostat এর efficacy ভালো, তবে Allopurinol এর দাম কম, Febuxostat এর দাম বেশি.

আবার Cardiovascular safety more in Allopurinol than Febuxostat.

তার মানে HTN patient, /IHD patient with Gout: Drug of choice Allopurinol

যাদের Allopurinol er tolerance capacity কম কিংবা Allergic reaction হয়, তাদের জন্য Febuxostat.

Allopurinol এ কাজ না করলে Febuxostat.

— >Allopurinol এর ডোজ-

100 mg দিয়ে শুরু করবে, ১ সপ্তাহ পরে বাড়াবে, এর পরে দৈনিক 300 mg করে দিবে.

Tablet 1.Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout).FOR 7days then will be used Tablet 2.Purinol 300mg (AS A A Allopurinol AS A Drugs used in Gout) (0+1+0) for 3month.

Indications of of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout).

Esloric is indicated for reducing urate/uric acid formation in conditions where urate/uric acid deposition has already occurred (e.g. gouty arthritis, skin tophi, nephrolithiasis). Esloric is indicated for management of 2,8-dihydroxyadenine (2,8-DHA) renal stones related to deficient activity of adenine phospho ribosyltransferase. Esloric is indicated for the management of recurrent mixed calcium oxalate renal stones in the presence of hyperuricosuria, when fluid, dietary and similar measures have failed.

Pharmacology of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

Allopurinol is a xanthine oxidase inhibitor which is administered orally. It acts on purine catabolism without disrupting the biosynthesis of purines. It reduces the production of uric acid by inhibiting the biochemical reactions immediately preceding its formation. Allopurinol is a structural analogue of the natural purine base, hypoxanthine. It is an inhibitor of xanthine oxidase, the enzyme responsible for the conversion of hypoxanthine to xanthine and xanthine to uric acid, the end product of purine metabolism. Allopurinol is approximately 90% absorbed from the GI tract. Peak plasma levels generally occur at 1.5 hours to 4.5 hours. It has a plasma half life of about 1 to 2 hours. Approximately 20% of the ingested Allopurinol is excreted in the faeces.

Dosage & Administration of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

Adults: Allopurinol should be introduced at low dosage e.g. 100 mg/day to reduce the risk of adverse reactions and increased only if the serum urate response is unsatisfactory. Extra caution should be exercised if renal function is poor. The following dosage schedules are suggested:

100 to 200 mg daily in mild conditions,
300 to 600 mg daily in moderately severe conditions,
700 to 900 mg daily in severe conditions.

Children: Children under 15 years: 10 to 20 mg/kg body weight/day up to a maximum of 400 mg daily. Use in children is rarely indicated, except in malignant conditions (especially leukaemia) and certain enzyme disorders such as Lesch-Nyhan syndrome.

Elderly: In the absence of specific data, the lowest dosage which produces satisfactory urate reduction should be used.

Dosage in renal impairment: In severe renal insufficiency, it may be advisable to use less than 100 mg per day or to use single doses of 100mg at longer intervals than one day.

Interaction of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

When 6-mercaptopurine or azathioprine is given concurrently with Esloric, only one-quarter of the usual dose of 6- mercaptopurine or azathioprine should be given because inhibition of xanthine oxidase will prolong their activity. Evidence suggests that the plasma half-life of vidarabine is increased in the presence of Esloric. When the two products are used concomitantly extra vigilance is necessary, to recognise enhanced toxic effects. Theophylline levels should be monitored in patients starting or increasing Esloric therapy. An increase in frequency of skin rash has been reported among patients receiving ampicillin or amoxicillin concurrently with Esloric compared to patients who are not receiving both drugs. Reports suggest that the plasma concentration of ciclosporin may be increased during concomitant treatment with Esloric.

Contraindications of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

Allopurinol tablet is contra-indicated in patients with known hypersensitive to allopurinol.

Side Effects of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

Rashes, gastro intestinal disorder’s, rearly malaise, headache, vertigo, drowsiness, visual and test disturbances, hypertension, alopecia, hepatotoxicity, neuropathy, gynaeconastia and blood disorders.

Pregnancy & Lactation of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

There is inadequate evidence of safety of Allopurinol in human pregnancy. Use in pregnancy only when there is no safer alternative and when the disease itself carries risk for the mother or unborn child. There are no data concerning the effects of allopurinol or its metabolites on the breast-feed baby.

Therapeutic Class of Tablet:-Esloric 100mg (0+1+0 )(AS A Allopurinol AS A Drugs used in Gout)

Drugs used in Gout

–> Febuxostat 40 mg once daily দিয়ে শুরু করবে, ১ সপ্তাহ পড়ে 80 mg করবে.

purinol 100 mg, and 300 mg নামে পাওয়া যায়,

–> Febuxostat – Febus 40 and 80 mg নামে পাওয়া যায়..

Tablet 2:-Febus 40 mg (0+1+0) For 1^st 7days Only (AS A Febuxostat As a Drugs used in Gout)

Then Tablet 2.Febus 80 mg (0+1+0) For 3 Months.

Indications of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

Febus tablets are indicated for the chronic management of hyperuricemia in patients with gout. Febus tablets are not recommended for the treatment of asymptomatic hyperuricemia.

Pharmacology of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

Febuxostat is a non-purine, selective xanthine oxidase (XO) inhibitor. It decreases serum uric acid level by inhibiting xanthine oxidase, which is responsible for uric acid production. Xanthine oxidase breaks down hypoxanthine to xanthine and thus to uric acid. Febuxostat is not expected to inhibit other enzymes involved in purine and pyrimidine synthesis and metabolism at therapeutic concentrations.

Dosage & Administration of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

The recommended starting dose: Febuxostat 40 mg tablet once daily. For patients who do not achieve a serum uric acid less than 6 mg per dL after 2 weeks with Febuxostat 40 mg tablet, One Febuxostat 80 mg tablet once daily is recommended. If serum uric acid less than 6 mg per dL after 2-4 weeks with Xanuric 80 (Febuxostat 80mg) tablet, then one Febuxostat 120 mg tablet once daily is recommended.

Tumor Lysis Syndrome: The recommended dose is one Febuxostat 120 mg tablet once daily. Febuxostat 120 mg tablet should be started two days before the beginning of cytotoxic therapy and continued for a minimum of 7 days. However treatment may be prolonged up to 9 days according to chemotherapy duration as per clinical judgment.

Gout Flares: Gout flares may occur after initiation of Feboxostat tablets due to changing serum uric acid levels resulting in mobilization of urate from tissue deposits. Flare prophylaxis with a non-steroidal anti-inflammatory drug (NSAID) or colchicine is recommended upon initiation of Febuxostat tablets. If a gout flare occurs during treatment, Feboxostat tablets need not be discontinued. The gout flare should be managed concurrently, as appropriate for the individual patient.

Renal impairment: No dose adjustment is necessary when administering Febuxostat in patients with mild to moderate renal impairment.

Hepatic impairment: No dose adjustment is necessary in patients with mild to moderate hepatic impairment.

Pediatric Use: Safety and effectiveness in pediatric patients under 18 years of age have not been established

Contraindications of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

Febuxostat is contraindicated in patients being treated with azathioprine, mercaptopurine, or theophylline.

Side Effects of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

The most commonly reported adverse reactions are gout flares, liver function abnormalities, diarrhoea, nausea, headache, rash and oedema. These adverse reactions were mostly mild or moderate in severity. Rare serious hypersensitivity reactions to Febus have observed.

Pregnancy & Lactation of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women. Febuxostat should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. It is not known whether this drug is excreted in human milk. Caution should be exercised when Febuxostat is administered to a nursing woman.

Therapeutic Class of Tablet :-Febus 40 mg (AS A Febuxostat As a Drugs used in Gout).

Drugs used in Gout

√√ Scenario —

Sanjida ahmed 27 years old suffering from pain in her 1st metatarsophalngeal joint for 3 days. And there are painful swelling in her great toe, on examination Localised tenderness and redness and local temperature raised…

Lab investigation done.

Serum uric acid 9 mg/dl.

√√ Whats is your diagnosis and how will you manage this case?

MX of acute gouty attack and how to prevent recurrent attack…..

Answer is:-Acute condition e 1st line of Drug should be Colchicine Not Allopurinol.

Chronic Condition + CKD on MHD er patient er khetre apni Febuxostat use korben .

2.. Febixostat 40 mg BD

4 weeks, if not decrease, double the dose.

For more 8 weeks

Raiyyan Tahsan. Date:23-01-2025 Thursday Time:5-00-35 PM

Raiyyan Tahsan

Raiyyan Tahsan