crystalline arthropathy (gout) Flashcards
what is gout
uric acid (monosodium urate) deposits in soft tissues, joints and bones
6 diseases that causes secondary hyperuricemia
lymphoproliferative disorders
psoriasis
CHF
CKD
preeclampsia
dehydration
4 drugs causing secondary hyperuricemia
thiazides
furosemide
aspirin
teriparatide
chemotherapy
+ pyrazinamide & ethambutol
when can you treat asymptomatic hyperuricemia with urate-lowering agents
persistent in the infrequent patient with serum urate over 13 mg/dl (men) or 10 mg/dl (women)
severe, sudden, disabling symptoms with intensity by 12-24hrs and resolves in days to weeks +/- treatment
acute gouty arthritis
which condition has predilection to LE, with MTP being the first joint then midfoot then ankle?
acute gouty arthritis
some predisposing/triggering factors to gout (5)
- trauma
- surgery
- starvation or dehydration
- dietary overindulgence
- drugs that raise or lower serum urate–allopurinaol, uricosuric agents, thiazide or loop diuretics, low dose aspirin
of these 7 things, we need 6+ points to be able to make clinical diagnosis of gout.. list the 7 things.
- serum uric acid over 5.88 = 3.5 pts
- first MTP joint = 2.5 pts
- male = 2
- previous attack = 2
- HTN or a CVD = 1.5 points
- joint redness = 1 point
- onset w/in one day = 0.5 point
what is the condition?
on microscopy– negatively birefringent needle-shaped crystles with increased WBC count (under 50K)
gout
confirmatory diagnostic test for both gout and pseudogout
arthrocentesis
what stage of gout
asymptomatic between attacks but will likely have second attack w/in 2 yrs if untreated
might end with chronic tophaceous gout if untreated
intercritical gout
Gout crystals anywhere in soft tissue deep in skin. you poke it and it comes out like toothpaste
tophaceous gout
first line tx of acute gout? who can’t get this treatment? if they cant get it then what?
- ist line: high dose NSAID
- NSAID C/I: renal insufficiency, active DU or GU, CVD
- instead give them steroids (intraaricular if under 2 joints or oral prednisone 30-50mg, taper over 10 days)
when is colchicine used in gout? (2) when is it avoided? (1)
- acute: if its worked in the past and they can’t use an NSAIDs; works weakly in acute cases though
- can also be used as 2nd line in chronic gout
- avoid in kidney disease
ADR of diarrhea, bone marrow suppression (neutropenia)
colchicine
what is the condition
radiograph shows punched out erosions with sclerotic & overhanging margins– mouse/rat bite lesions
gout– bone resorption secondary to tophi formation in the bone
2 renal complications of hyperuricemia
renal stones/urolithiasis
chronic urate nephropathy
6 indications fo urate-lowering therapy
- recurrent gouty attacks that affect patients life
- tophaceous gout
- renal stones d/t uric acid (24 hr urine to confirm)
- very high uric acid levels
- urate nephropathy
- tumor lysis syndrome
what is the treatment target for uric acid when doing urate lowering therapy
below solubility of 6 mg/dL
- xanthide oxidase inhibitor that causes decreased production of uric acid; first line prophylaxis for gout
- prevents urate nephropathy from tumor lysis syndrome
- Start w/ 100 mg daily when renal function above 40 & increase slowly
allopurinol
ADR of rash, leukopenia or thrombocytopenia, diarrhea, drug fever
allopurinol
what are the two urosurics not on our med list but can be used for chronic gout; C/I in renal failure & urate overproducers
probenecid
sulfinpyrazone
clinical manifestations that happen bc of CCP deposition into cartilage of joints
calcium pyrophosphate deposition disease (CPPD)
incidental finding of chondrocacinosis on radiograph or genu varus on P.E
asymptomatic CPPD
self-limited acute or subacute arthritis attacks occasionally associated w/ systemic sx of fever, leukocytosis
- knees, wrists, elbows, MCP, shoulders, etc
pseudogout– tends to last longer than gout
nonerosive, inflammatory arthritis where there is CPPD crystals in joint fluid; affects MCP & wrists; associated w/ fatigue and AM stiffness
pseudo-RA/ chronic CPP inflammatory arthritis—- real RA is erosive
progressive disease +/- acute/subacute episodes of pseudogout; affects knees, first CMC, atypical joints (wrists, MCP joints, hips, shoulders, spine, patellofemoral joint)
pseudo OA
- real OA isn’t at the patellofemoral joint, affects the patellar
4 conditions that might lead to chondrocalcinosis
hemochromatosis– younger males
hyperparathyroidism- older males
low Mg
hypophosphatasia
similar to charcot joint; uncommon presentation of CPPD
pseudo-neuropathic joint disease
micoscopy shows positively birefringent crystalls, rhomboid shaped & increased WBC (under 50K)
arthrocentesis of pseudogout
radiograph shows linear calcification of cartilage to support diagnosis
pseudogout
first line for acute pseudogout
1st line: intraarticular steroids if less than 2 joints; NSAIDs if over 2??
1st & 2nd line for chronic pseudogout if having attacks more than 3x/yr
1st line: colchicine
2nd line: NSAIDs
other than medication for pseudogout, what else can you do for prophylaxis of pseudogout
manage underlying disease– hyperparathyroidism, low lmg, hemochromatosis
