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General practice > Gout > Flashcards

Gout Flashcards

1
Q

Natural history (4)

A

Natural history=

  1. asympT hyperU
  2. acute arthritis
  3. intercritical gout
  4. chronic tophaceous
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2
Q

Pathogenesis

A

+uric acid (from purine metabolism)–>
not all hyperuricemia= gout
Precipitation of monosodium urate into joint->+in periphery where -ve temperature
Urate crystals form–>incitng event
(trauma?) released in to synovium-
+inflammation
MacroP ingest-> +inflammasome->+neutrophils->+free radicals, leukotrienes, joint damage->neutrophils ingest, lyse and release lysosomal factors

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3
Q

Renal metabolism influencing gout (4)

A

-ve glomerular filtration
-ve excretion
+absorption
+post secretion reabsorption

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4
Q

Risk factors (7)

A 
Hyperuricemia
Age >30, male
Heavy alcohol
Obesity
Drugs->diuretics/aspirin, cyclosporin
genetics
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5
Q

Complications (5)

A 
Nephropathy
Chronic gouty tophy
Pyeloneprhitis
Nephrocalcinosis
Hypertension
Atherosclerosis
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6
Q

Association with CVD

A

+LDL, -ve HDL. Must do CVD risk assessment

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7
Q

Morphology in chronic

A

Chronic–>precipitation on
cartilage. Becomes fibrotic, thickened,
pannus forms. erosions,
fibrous ankylosis

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8
Q

Morphology of gouty tophy

A 
\+aggregates urate
crystal w/ surrounding
macroP, lymphocytes
In joint/cartilage surface
periarticular tissues-->
patellar bura, olecronon,
earlobe, achilles tendo and
elsewhere
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9
Q

Morphology of nephropathy

A

precipitate in interstitium,
tubules–>
uric acid stones, pyelonephritis

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10
Q

Morphology of acute

A 
Acute--> neutrophilic
aggregates (w/ crystals inside),
edematous, congested. some
macroP, lymphocytes. when
crystals solubilised, attack abates
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11
Q

Where are tophy found

A

Extensor surfaces->elbows, knees, achilles, helix of ear

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12
Q

Diagnosis

A

Arthrocentesis:
WCC usually exceeds 2.0 x 10^9/L
PMN
Monosodium urate crystals, negative birefringent

Serum uric acid may be low, normal or high

Search for secondary causes->renal insufficiency, +cell turnover in malignancy

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13
Q

When is treatment for hyperuricemia indicated

A 
Recurrent gout
Uric acid neprhopathy
Urolithiasis
Tophi
Comorbidities putting at +CVD risk
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14
Q

Management of acute

A
  1. NSAID- indomethacin
  2. Colchicine
  3. Prenisilone
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15
Q

Why is colchicine less often use

A

Side effects-> GIT

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16
Q

Prevention

A

Low purine diet
Limit alcohol and fructose containing drinks
Avoid drugs that worsen
Lose weight, reduce CVD risk

Consider urate lowering therapy + colchicine+/- NSAID (to prevent acute attack)

17
Q

Best time to commence urate lowering therapy

A

Intercritical gout

18
Q

Urate lowering therapy

A

allopurinol 50 mg orally, daily for the first month, then increase the dose by 50 mg every 2 to 4 weeks depending on the patient’s renal function and plasma urate levels

19
Q

Management of chronic gout

A

Allopurinol
Colchicine
NSAID

20
Q

Alternative if colchicine or NSAID CI/not tolerated

A

Prednisilone

21
Q

How to prevent acute attack when starting on allopurinol

A

Wait 3 weeks from acute attack

Cover with NSAID/colchicine for 3 months.

22
Q

Allopurinol SE

A

Rash, fever, -ve WCC

Caution in renal impairment

23
Q

Acute pseudogout

A

Acute monoarthropathy
Large joints
Spontaneous and self limiting

24
Q

Provoked pseudogout

A

Surgery
Illness
Trauma

25
Q

Risk factors for pseudogout

A 
Age +
OA
DM
Hypothyroidism
\+PTH
Haemachromatosis
Wilsons
Low PO4,Mg
26
Q

Microscopic findings for PPD

A

Weakly birefringent

27
Q

What condition is PPD associated with

A

Chondrocalcinosis->soft tissue calcium deposition

28
Q

Management of PPD

A

NSAId, analgesia

29
Q

Advice to patients

A

Foods that have a high purine content (i.e., alcohol, seafood, and offal) are associated with higher risk of elevated uric acid and gout. [2]

Reducing intake of alcohol, especially beer, lowers the risk of gout. [31]

Reducing seafood and meat intake helps to a lesser degree.

Reducing the intake of vegetables high in purines (i.e., asparagus, spinach, and mushrooms) does not seem to affect uric acid levels.

Dairy products reduce the risk of gout.

30
Q

Monitoring recommendations in gout

A

Recurrent attacks, tophy, radiographic changes
F/U uric acid levels 1-3 monthly, then 6 monthly
FBC, RFTs, LFTs every 3-6 months
When begin on allopurinol, monitor for hypersensitivity
Consider drug interactions

31
Q

Crystals seen on polarising microscopy

A

Monosodium urate
Calcium pyrophosphate dehydrate
Calcium hydroxyappatite
Calcium oxalate

32
Q

Appearance of CPPD

A

Rod
Rhomboid
Weakly birefringent

33
Q

Appearance of calcium oxalate, and when do they occur

A

Bipyramidal
Strong +ve birefringent
End stage renal

34
Q

What is the term for gout of first MTP joint

A

Podagra

35
Q

When is monitoring uric acid levels useful

A

Monitoring in hypouricemic therapy

36
Q

Radiographic appearance of gout

A

Cystic changes in joint surface
Punched out lesions
Soft tissue calcifications

General practice (26 decks)

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