Crytal Induced Arthitis

Question 1

What is the general onset of Gout in men and women

Answer 1

90% of patients are men. Usually 30 years and up

If occurring in women, typically onset is postmenopausal

Question 2

Lab value for hyperurecemia

Answer 2

Hyperuricemia: defined as a serum urate level of 6.8 mg/dL or greater

—the necessary precursor for the development of gout

Question 3

What is the end product of purine metabolism

Answer 3

Uric Acid

Question 4

What are the CANT LEAP drugs for Gout

Answer 4

Cyclosporine

Alcohol

Nicotinic Acid

Thiazide Diurectis

Lasix (loop diuretics)

Ethambutol

Aspirin

Pyrazinamide

Question 5

Do NML levels of Uric acid R/o gout?

Answer 5

NO!

Question 6

How does gout present on CBC

Answer 6

Leukocytosis w/ increased polymorphonuclear leukocytes

Question 7

What are the synovial fluid findings for Gout

Answer 7

Leukocyte count between 5,000 and 80,000 cells

Polymorphonuclear leukocytes

Negatively birefringent crystals
(bright yellow needle-shaped objects)!!

Question 8

What is a double contour sign on U/s

Answer 8

Sign for Gout

Superficial, hyperechoic band on the articular cartilage

Question 9

6/12 criteria to Dx Gout in the absence of Bifringent Crystals

Answer 9

1. More than one attack of acute arthritis
2. Maximal inflammation developed within 1 day
3. Attack of monoarticular arthritis
4. Joint redness observed
5. First metatarsophalangeal joint painful or swollen
6. Unilateral attack involving first metatarsophalangeal joint
7. Unilateral attack involving tarsal joint
8. Suspected tophus
9. Hyperuricemia
10. A symptomatic swelling within a joint (radiograph)
11. Subcortical cysts without erosions (radiograph)
12. Negative culture of joint fluids for microorganisms during attack of joint inflammation

Question 10

What is the uric acid goal for Gout Tx

Answer 10

Maintain uric acid levels ≤6mg/dL

Question 11

How long do we maintain Tx for Gout flares

Answer 11

Maintain treatment for 48-72 hours after flare resolves to reduce risk of relapse

Question 12

What are the three Rx approach to Gout

Answer 12

Max dose NSAIDS (indomethacin)
+ Colchicine (1.2 mg initially, then 0.6 @ 1 hour) (max: 1.8mg/hr)

Corticosteroids if unable to take nsaids (prednisone 0.5mg/kg/day)

Question 13

What is the prevention Rx dose for colchicine and gout

Answer 13

0.6 mg BID

Max: 1.2 mg / day

Question 14

What are the reversible causes of gout

Answer 14

High purine Diet

Obestiy

ETOH (BEER)

Question 15

When should you initiate Urate Lowering Tx

Answer 15

One or more tophi

Frequent attacks

2+ attacks a year

CKD stage 2 or worse

Nephrolithiasis

(Goal is <5.0 if tophi present)

Question 16

What is the agent of choice to reduce Urate

Answer 16

Allopurinol

Combined with colchicine

Question 17

When would Probenecid be used for Gout

Answer 17

Second line medication that improves uric acid excretion

Use only if renal function is preserved

• Nephrolithiasis is a common adverse effect
• Can increase blood levels of methotrexate and ketorolac to toxic levels
• Use in those under 65 years of age

Question 18

What is the Rx for a pt with SEVERE gout with multiple tophi

Answer 18

Pegloticase

Question 19

What defines psuedo Gout

Answer 19

Calcium Pyrophosphate dihydrate crystal deposits
(Rhomboid)

MDC to the KNEE

Can be primary or 
Secondary
-Hyperparathyroidism 
-hemochromatosis 
-hypothyroidism 
-low Mg2+ or PO4-

Question 20

What is the common flare up for psuedo gout

Answer 20

Following trauma or procedures

Question 21

What is the most common type of psuedogout

Answer 21

Osteoarthritis with CPPS is the MC form of symptomatic CPPD (~50%)

Question 22

What is the definitive Dx criteria for Psuedo Gout

Answer 22

Definitive diagnosis requires presence of both CPP crystals by synovial fluid analysis AND chondrocalcinosis on radiographs

Question 23

Treatments for Chronic Psuedo Gout

Answer 23

treat acute the same as Gout

Chronic:
May try colchicine or low dose prednisone
+/- DMARDS
+/- Duloxetine, capsaicin, DICLOFENAC GEL!