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Rheumatology > Gout > Flashcards

Gout Flashcards

1
Q

What is gout?

A

A crystral arthropathy

Disorder of the purine metabolism

Characterised by raised uric acid levels and deposition of urate crystals in joints and other tissues (e.g., soft CT or the UTI)

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2
Q

What is pseudogout?

A

Crystalline, inflammatory, asymmetrical mono-/oligo-/polyarthritis

Involves the peripheral joints due to deposition of microscopic crystals (CPPD) and more commonly in the elderly

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3
Q

What is the incidence of gout?

A

1.77 per 1000 person years

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4
Q

What is the prevalence of psuedogout?

A

7-10% in over 60s (UK)

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5
Q

Which sex does gout affect more?

A

M > F (4.3:1)

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6
Q

What is the typical age of onset for gout?

A

30-40 years

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7
Q

Which sex does pseudogout affect more?

A

F and M equally affected

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8
Q

Which continents have a higher prevalence in gout?

A

Oceania, North America and among indigenous populations e.g., Māori, Aboriginals, and Inuit

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9
Q

What are the risk factors for gout?

A

Beer (i.e., alcohol)

Meat, seafood (i.e., high protein diet)

Fructose

FHx

Medications

Obesity

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10
Q

List the medications that can increase the risk of gout

A

ACEis

β blockers

Ciclosporin

Diuretics

Pyrazinamide

Tacrolimus

Ritanovir

Lead exposure

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11
Q

What are the risk factors for pseudogout?

A

Elderly

If young:
-hyperparathyroidism
-haemochromatosis

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12
Q

What is the pathogenesis of gout?

A

Increase uric acid level

Leads to formation of monosodium urate crystals

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13
Q

What is the pathogenesis of pseudogout?

A

Formation of calcium pyrophosphate dihydrate crystals (CPPD)

Deposits in joints causing inflammation and pain

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14
Q

TRUE OR FALSE

Gout has positively birefringent crystals

A

FALSE

Has strongly NEGATIVE birefringent needle like crystals

It is pseudogout that has POSITIVE birefringent rhomboid shaped crystals

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15
Q

Which joints does gout normally affect first and in what order?

A
  1. Big toe
  2. Knee

N.B – smaller joints first then larger joints

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16
Q

Which joints does pseudogout normally affect first and in what order?

A
  1. Knee
  2. Wrist
  3. Ankle
  4. Elbow
  5. 2nd and 3rd MCP
  6. Shoulders
17
Q

What would you expect to see on examination of someone with gout?

A

Joint is:
Erythematous
Swollen
Hot

Tophi in joints - normally not painful,

18
Q

What would you expect to see on X-ray for gout?

A

Acute = normal

Chronic = well-demarcated erosion

19
Q

What blood test would you do for gout and what would you expect to see?

A
  • Hyperuricaemia - (serum uric acid >6.8 mg/dl (404 µmol/l))
  • Raised WBC
  • Raised ESR
20
Q

What are the diagnostic tools that can be used for gout?

A

Arthrocentesis with synovial fluid analysis – 1st line

Blood tests – serum uric acid levels, dual energy computed tomography (DECT)

X-ray of affected joint

21
Q

What is the management of gout?

A

1st line = treat pain + inflammation – NSAIDs (continue until 1-2 days after initial acute episode) /colchicine. Can also give short course of oral corticosteroids

Reduce inflammation – steroids which can be injected into joint space if NSAIDs or colchicine are not tolerated or are ineffective

Lifestyle change – reduce meat and alcohol consumption to reduce uric acid consumption

Prophylactic medications – allopurinol and febuxostat which inhibit xanthine oxidase an enzyme that is involved in uric acid production

22
Q

What follow-up should be arranged for people with acute gout in primary care?

A

Review after 4-6 weeks to:
- measure serum urate levels

  • explain what gout is and that it is lifelong, risk factors, how to manage flares, lifestyle changes, where to find information
  • review meds (see which ones could be causing the gout)
23
Q

For someone with HTN on diuretics what should you do to manage their gout?

A

Consider changing to an alternative antihypertensive provided their BP is well controlled

24
Q

For someone with HF on diuretics what should you do to manage their gout?

A

Continue diuretics during an acute attack

25
Q

For someone with HF on NSAIDs to manage pain from gout, how should they be monitored?

A

Monitor renal function closely

26
Q

What is the prognosis of gout?

A

Acute attacks usually self-limiting – resolves completely in 1-2 weeks without treatment

Attacks recur in 62% of people within a year

Recurrent attacks and chronic gout lead to progressive joint damage, pain and disability

27
Q

How should pseudogout be managed?

A

Pain -NSAIDs/colchicine

Reduce inflammation – intrarticular steroid injections/systemic steroids

Cannot use allopurinol/febuxostat as pathogenesis is different to gout

28
Q

What is the prognosis of pseudogout?

A

Acute attacks usually resolves within 10 days

Some patients may go on to develop progressive joint damage with functional limitation

29
Q

What other DDx should be considered for gout?

A

Septic arthritis

OA

RA

Reactive arthritis

Bursitis, cellulitis, tenosynovitis

Trauma

Haemochromatosis

30
Q

What other DDx should be considered for pseudogout?

A

Acute gout

Septic arthritis

OA

RA

31
Q

What steroid is given for acute gout, how long for and at what dose?

A

Prednisolone

30-35mg OD

3-5 days

N.B. this is an off-label use of oral corticosteroids

32
Q

Sources

A

https://bestpractice.bmj.com/topics/en-gb/13

https://cks.nice.org.uk/topics/gout/management/acute-gout/

https://patient.info/doctor/calcium-pyrophosphate-deposition-including-pseudogout-pro

33
Q

What is the typical dose of colchicine given in acute gout?

A

500 micrograms

2–4 times a day until symptoms relieved

maximum 6 mg per course

do not repeat course within 3 days.

34
Q

What are the side effects of colchicine?

A

Common/very common
- abdo pain
- N+V
- diarrhoea

Frequency unknown
- agranulocytosis
- alopecia
- bone marrow disorders
- GI haemorrhage
- kidney injury
- hepatic injury
- menstrual cycle irregularities
- myopathy
- nerve disorders
- rash
- sperm abnormalities
- thrombocytopenia

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