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BPT Rheumatology > Gout > Flashcards

Gout Flashcards

1
Q

WHat is the prevalence of gout in Australia

A

5.2-6.8% (M8.5 F2.1)

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2
Q

Which ethnic groups have higher prevalence?

A

Maori and pacific islanders

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3
Q

What is the pathiophys?

A

Hyperuricaemia > precipitaiton of monosodium urate in joints > inflammation

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4
Q

What is the solubility threshold for monosodium urate?

A

0.405mmol/L

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5
Q

What is urate a end-product of?

A

Purine catabolism

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6
Q

Which is the precursors and what converts it into urate?

A

Xanthine, xanthine oxidase

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7
Q

What are the mechanisms effecting urate levels?

A

Intrinsic production
Extrinsic intake
Excretion

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8
Q

How is urate excreted

A

Renal and GIT

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9
Q

What proportion of urate overproduction is intrinsic?

A

10%

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10
Q

What are the 3 inborn errors of metabolism leading to primary urate over-production?

A

Accelerated purine synthesis - PRPP synthase enzyme hyperactivity
Impaired purine salvage - HGPRT1 deficiency
Hereditary defect of energy metabolism

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11
Q

Which syndrome has complete HGPRT1 deficiency? Which has partial?

A

Complete - Lesch-Nyhan syndrome

Partial - Kelley-Seegmillar syndrome

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12
Q

What conditions lead to 2nd over production of urate?

A

Autoimmune and haemolytic aneamia
TLS
Myeloproliferative disorders

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13
Q

What foods are high in purine

A

Seafood
Red meat - organ meat
Fructose containing
Alcohol

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14
Q

How does alcohol increase urate

A

Liver damage - increased purine turner
Increased lactate reduces renal excretion
Beer - high in purine

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15
Q

What is the urate transporter in the GIT?

A

ABCG2

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16
Q

WHere is urate reabsorpted?

A

Prox tubule 90-98%

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17
Q

What are the renal transporters of urate?

A 
URAT1; OAT4
Glut9a
OAT1
ABCG
MRP4, NPT1, NPT4
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18
Q

How does CKD lead to high urate?

A

Decreased filtered urate load

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19
Q

Which medications lead to under secretion?

A

Diuretics
Low dose aspirin
Pyrazinamide
Ciclosporin

20
Q

Which receptors recognise MSU crystals?

A

TLR 2 and 4

21
Q

Which cytokine is produced?

A

IL-1

22
Q

What mechanisms self-limit gout flares?

A

Coating of cystals with synovial fluid proteins - inhibit phagocytosis
Release of local anti-inflam molecules eg ACTH
NETs

23
Q

How does gout present?

A

Acute gout flare
Subcut tophi
Chronic gouty arthritis

24
Q

Which joints are affected?

A

Any. Most commonly 1st MTP

25
Q

How long does pain take to occur with an acute flare?

A

4-12 hours

26
Q

How long does an acute flare take to resolve?

A

1-2 weeks

27
Q

What are tophi?

A

Network of MSU crystals plus host response factors

28
Q

What are the DDx of gout?

A 
CPPD
Septic arthritis
Trauma
Spondyloarthritis
Sarcoidosis
29
Q

How do MSU appear on polarized light microscopy?

A

Intra-cellular needle shaped, negatively birefringent crystal

30
Q

What are the characteristic gouty x-ray erosions?

A

Overhanging edge with sclerotic margin

31
Q

What are the US signs of gout?

A

Double contour sign
Hyperechoic aggregates
Tophi

32
Q

Options for acute gout flare management?

A

NSAIDs, COX-2 inhibitors
Prednisolone - high doses often required
Colchicine 1mg immediately, the 0.5microg one hour later (renally adjusted)
Intra-articular corticosteroid injection

33
Q

What are the urate lower therapy options?

A

Xanthine oxidase inhibitors
- Allopurinol, febuxostat
Uricosuric agent (promote urinary excretion)
- Probenicid

34
Q

How do you dose allopurinol?

A

100mg daily at commencement (50mg if eGFR <60)
increased by 50-100 every 2-4 weeks until target reached
Max 800-900mg daily

35
Q

What is the urate target?

A

<0.36mmol/L in all patient

<0.30 in severe gout - frequent flare, tophi, erosions

36
Q

How does allopurinol hypersensitivity snydrome present (AHS)?

A

Desquamating rash, fever, eosinophilia, end-organ damage

37
Q

How do you prevent AHS?

A

Renally adjust initial dose

38
Q

Why does ULT increased risk of flare?

A

Mobilise MSU crystals

39
Q

When to use fexuxostat?

A

If allopurinol contraindicated or not tolerated?

40
Q

What did the CARES trial show?

A

All-cause mortality and CV mortality higher with febuxostat compared to allopurinol

41
Q

What is the mechanism of uricosuric therapy?

A

Inhibit URAT1 and GLUT9 (urate resorption transporters) in the prox tubule

42
Q

What is the uricosuric therapy available in Australia and when don’t you use it?

A

Probenecid

Hx of nephrolithiasis and severe CKD

43
Q

What can you use for prophylaxis which on ULT?

A

Low dose colchicine 500microg daily
Low dose NSAID (eg naproxen 250mg BD)
Low dose prednisoloen

44
Q

How long do you continue prophylaxis

A

6 months from initiation of ULT

45
Q

When don’t you use/reduce dose colchicine?

A

CKD

Statin therapy

BPT Rheumatology (17 decks)

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