Gout and CPPD dx Flashcards
Before starting allopurinol, what do you do?
Order HLA-B 5801 allele
Do this for pts who are high risk for hypersensitivity (DRESS) with allopurinol
Who is at risk for allopurinol hypersensitivity?
CKD, ethnicity (Thai, Han Chinese, Korean)
allopurinol is contraindicated in GFR<30
diuretic use is a risk factor
Allopurinol hypersensitivity
See DRESS (drug reaction, eosinophilia, and systemic symptoms)
Can probenecid be given to patients with CKD and gout
no, needs intact renal function.
Febuxostat
non competitive xanthine oxidase inhibitor ok for mild to moderate CKD and second line after failing allopurinol (with limited approval)
only used for chronic management and NOT for acute gout attack.
Black box warning of febuxostat
increased risk for cardiovascular death and mortality (FDA 2/2019)
Calcium pyrophosphate deposition disease or CPPD is also called
pseudogout and a crystal induced arthropathy.
See rhomboid shaped weakly positively bi refringent crystals on joint fluid analysis
CPPD crystal arthropathy
most commonly affected joint with Calcium pyrophosphate deposition disease
knee
what do you see on XR of knee with Calcium pyrophosphate deposition disease?
chondrocalcinosis - calcium deposition in cartilege
Treatment of Calcium pyrophosphate deposition disease
aspiration of fluid followed by a short course of NSAIDS or intraarticular steroid injection.
if there’s fewer than three joints involved
Before giving a steroid injection to treat someone with CPPD, what should you do first
rule out septic joint based on feer, leukocytosis, examination under Gram stain and culture.
How do you treat pts who have multiple joints involved with CPPD arthropathy?
colchicine (if started within 24 hrs of symptomon onset, NSAIDS and oral steroids).
ineffective to give intraarticular steroid injection with so many joints involved
what medication can you give to prevent future CPPD attacks?
colchicine
refractory cases of CCPD - give immunosuppression with hydroxychloroquine, methotrexate.
can give NSAIDS for pain.
Medications that increase risk for gout
diuretics and low dose aspirin, beta blockers, ACEi and ARBS (except losartan)
risk factors for gout
surgery, trauma, recent hospitalization
volume depletion
diet: high protein foods (meat and seafood), high fat foods, fructose or sweetened beverages
heavy ETOH consumption
underlying medical conditions like HTN obesity CKD and organ transplant
what foods decrease risk for gout:
low fat dairy product
vitamin C>1,500 mg/day
coffee intake >6 cups/day
how do loop diuretics increase risk for gout?
increases serum urate levels through both volume depletion and increased urate reabsorption in proximal tubule.
Thiazide diuretics also raise uric acid levels by acting as a counter-membrane transporter for urate and relatively contraindicated with gout
Gout is associated with
hyperuricemia hypertension obesity alcohol diuretics
Pseudogout is associated with
hypothyroidism hemochromatosis renal osteodystrophy hypomagnesemia hyperparathyroidism, recent parathyroidectomy
Affected joints of gout
1st metatarsal phalangea (50*90%)
ankle
knee
Name the commonly affected joints of pseudogout (CPPD)
knee (most common)
wrist
ankle
Synovial joint analysis of gout
needle shaped negatively birefringent, uric acid crystals
see 2000-100,000 WBC
XR of gout
subcortical bone cysts and possible bony erosions
synovial joint analysis of gout
rhomboidal positively birefringent calcium pyrophosphate crystals with 15-30K WBC
XR of pseudogout
chondrocalcinosis
what precipitates pseudogout
setting of trauma/overuse, surgery, and medical illness
what is osteitis fibrosa cystica?
rare complication of severe primary hyperparathyroidism with subperiosteal bone resorption in the middle phalanges and tapering of distal clavicles
See “salt and pepper” appearance of skull, bone cysts and brown tumors of long bones
when starting allopurinol what’s the target uric acid level?
Uric acid <6 mg/dl to reduce tophi burden and joint destruction in pts with frequent attacks of gouty arthritis.
when do we use fubuxostat?
second line urate lower therapy.
give if cannot tolerate allopurinol or do not reach target uric acid level (<6)
not used in acute gout flair
if on febuxostat for gouty arthritis, what lab to monitor?
monitor liver function tests
may not use fuboxostat as much in future due to new risk for CAD mortality.
Debunking myths of gout:
during gout attacks serum uric acid is low
serum uric acid levels are normal to low in acute gouty attacks.
They just need a history of this
debunking myths of gout:
acute gout does not require a uric acid measurement
uric acid should be lowered to <6mg/dl in pts with recurrent and tophaceous gout
high serum uric acid more likely suggests gout even without positive crystals in joint
debunking myths of gout:
colchicine should be dosed hourly
colchicine 0.6 mg 2-3 times daily is better tolerated and effective
debunking myths of gout:
allopurinol should be discontinued during an acute gout attack
changes in allopurinol dosing can worsen or precipitate acute gouty attacks
dose should be adjusted 3-4 weeks after gout attack
1st line treatment for gout attack
- NSAIDS. If already on ibuprofen or intolerant to NSAIDS, then colchicine.
- Give intra-articular steroids if 1-2 inflamed joints or contraindication to NSAID/colchicine
- colchicine
- Systemic steroids: >2 joints or NSAID/colchicine contraindication
indications for gout prophylaxis therapy are:
Try to avoid joint disability and future attacks.
nephrolithiasis, tophaceous gout, XR findings of gouty arthritis and urinary uric acid excretion>1100 mg/day
when do we use IV pegloticase?
tx for chronic gout refractory to other treatments. Will melt away gout
but always must check uric acid levels. If they start to rise it means body has started to make antibodies and another infusion of pegloticase can result in anaphylaxis.
Contraindications and
side effect of NSAIDs
contraindications in PUD, CKD, HF, (not great in Cirrhosis)
Side effects: GI bleeding, AKI, and sodium retention and edema
Contraindications and
side effect of colchicine
contraindication: CKD
side effect: diarrhea, abdominal cramps, bone marrow suppression and neuromyopathy
Contraindications and
side effect of intraarticular steroids
contraindication drug hypersensitivity
side effects: maybe hyperglycemia
suspected septic joint
Contraindications and
side effect of systemic steroids
contraindications: drug hypersensitivity
side effects: risk of rebound attacks, elevated HTN, elevated glucose, fluid retention
what blood pressure medications put a pt at risk for a gout flare?
diuretics (thiazides, loop diuretics)
beta blockers
ACE i
non losartan angiotensin II receptor blockers
which BP meds decrease risk for gout?
losartan
calcium channel blockers- amlodipine
preferred combination to treat pt who has gout and HIGH BP?
losartan plus calcium channel blocker
why does HCTZ increase risk for gout?
it it decreases excretion of urate and so should be avoided in pts with gout.
what do beta blockers do with a pt who has gout
increases risk for gout so should be avoided.
colchicine toxicity symptoms
proximal muscle weakness
myalgia and neuropathy
when do we see colchicine toxicity?
with CKD pts
see elevated CK kinase up to - fold
what is seen on colchicine toxicity muscle biopsy?
see cytoplasmic vacuolization
condition resolves with discontinuation of colchicine.
lifestyle interventions for gout:
caloric restriction, weight loss, reduced alcohol intake protein intake from vegetables, low fat diary products preferred over seafood, red meat and organ mena avoid diuretics (lasix and HCTZ increase uric acid levels)
when to initiate urate lower therapy when having a gout attack?
what urate level do you try to target?
wait until acute symptoms have resolved adjust dose to target uric acid level <6 use colchicine (or NSAIDs) to prevent flare during initiation and titration.
why dose ETOH increase gout attacks?
ETOH increases uric acid production. Beer in particular increases serum uric acid levels and increases the risk for initial and recurrent gout attacks. gout shoudl be counseled to limit ETOH to one or fewer beverages per day.
hemochromatosis causes
reduced clearance of calcium pyrophosphate crystals from synovial fluid.
can see CPPD dx from chondrocalcinosis and classic polyarthropathy (hooked like osteophytes in prominent 2nd and 3rd metacarpophalangeal joints) to acute pseudogout
do we treat pt who has chrondrocalcinosis seen on XR in triangle cartilege of hand if the pt has no symptoms?
no. don’t treat asymptomatic CPPD unless comorbid conditions like hyperparathyroidism or hemochromatosis.
when to start urate lowering therapy for recurrent gout?
start if there’s are any of the following:
two or more gout attacks in one year
one attack in the setting of CKD stage 2 or worse
one attack with presence of tophi visible on physical exam or imaging
one attack with history of urolithiasis.
pegloticase levels should be followed because?
IV porcine derived uricase (infused every 2 weeks)
monitor for uric acid levels to look for antibodies that manifest as rising serum urate levels. It means once antibodies have developed patient can have anaphylaxis to pegloticase exposure.
maximum dose of allopurinol is
800 mg per day for pts who have GFR<60
can titrate up in 100 mg increments
titration of allopurinol is with
100 mg increments
those with CKD start allopurinol at 50 mg increments as needed
drug should be discontinued with rash.
acute gout attack is treated with:
1st line: NSAIDs (or can do intra-artricular steroid injection)
2nd line: colchicine
3rd or 4th line is steroids.
ACR (american college of rheumatology) recommend trying to reduce serum urate levels to
<6 mg/dl without tophi
<5.5 mg/dl with tophi
can we use probenecid in pts who have CKD and recurrent nephrolithiasis
no.
what medications do you avoid adding together in a pt who is on colchine?
colchicine and clarithromycin
- coadministration of colchicine and clarithromycin can result in fatal colchicine toxicity that manifests as rhabdomyolysis, AKI and pancytopenia
Colchicine is metabolized in the liver by CYP3A4 cytochrome and should be avoided in tps taking CYP3A4 inhibitors like clarithromycin
there are fatal outcomes with both given at the same time.
ok to resume colchicine after recovery.
