Gout and polymyalgia treatment Flashcards
What is Gout
Sodium Urate Crystal Deposition in the joints- needle shaped
What is pseudogout
Calcium Pyrophosphate Crystal deposition in the joints
How come gout occurs
Abnormality in uric acid metabolism results in deposition of uric acid crystals that cause intermittent attacks of acute joint pain
Where does gout normally occur
Big toe
Can result in tophi (white nodules) in skin and around joints
What are the risk factors of gout
Family history Obesity Excess alcohol intake Ketosis High purine (red meat diet) Diuretics Acute infection Surgery
What is hyperuricaemia and how is it caused
Over production of uric acid, or most commonly, renal under excretion of uric acid
Causes:
Chronic renal disease
Drug therapy- thiazide diuretics, low dose aspirin
Hypertension
Increased lactic acid production (exercise, alcohol, starvation)
Hyperparathyroidism
Hypothyroidism
What does increased production of uric acid lead to
Increased purine turnover- myeloproliferative disorders, leukaemia, other cancers, psoriasis
How do you diagnose gout
Serum uric acid levels- normally raised
Joint aspirate- taking fluid from joint and looking for crystals
Renal function test- kidney function is adequate
X ray- look at joint erosion
How do you treat acute gout attacks
NSAIDS- naproxen
Can use Indomethacin, but doesn’t shown any specific advantage over NSAIDS
DON’T USE ASPIRIN
COLCHICINE
useful for heart failure patients
Corticosteroids
Intra-articular injection (monoarticular gout)
Intramuscular injection
What is the mechanism of action involved with the use of Colchicine in Gout
Prevents migration of neutrophils and phagocytes into gouty joints
Binds to tubulin to result in depolymerisation of microtubules and reduced cell motility
Prevents release of inflammatory products by these cells by preventing/limiting phagocytosis of urate crystals
How do you prevent gout lifestyle and taking which drugs away
Withdraw thiazides and salicylate
Lifestyle:
Loss weight
Reduce alcohol consumption
Change diet with reduced total calories and cholesterol and avoiding purine rich food (liver, red meat, fish, peas, spinach)
What drugs can you use for prophylaxis (prevention) of gout and when may yours them
Frequent recurrent attacks for more than 2 a year or tophi present or signs of chronic gout (joint erosion)
Reduce serum acid levels:
ALLOPURINOL: inhibits uric acid synthesis
URICOSURIC AGENTS: increase uric acid secretion from kidneys (probenecid and sulfinpyrazone)
Explain the mechanism of action behind allopurinol
Reduces uric acid synthesis through competitive inhibition of xanthine oxidase
Alloxantlhine (metabolite) also inhibits xanthine oxidase
Explain the mechanism of action behind uricosuric acid agents
Increases uric acid secretion by direct action on renal tubule
How is psuedogout caused and what does it affect on the body
Calcium pyrophosphate crystals that are deposited into articular cartilage and periarticular tissue
Affects:
Knees, shoulders and wrists
How do you diagnose psudogout
Blood tests- raised white blood cell count and normal serum calcium
X ray- calcification of articular cartilage (chrondrocalcinosis)
How do you treat pseudogout
Rest
joint aspiration with NSAIDs
Local corticosteroids can be useful
May need DMARDS if there’s joint erosion
What is juvenile idiopathic arthritis
Joint and limb pain that is common in child
How do you treat juvenile idiopathic arthritis
NSAIDS- relief of pain and stiffness
Children do not need DMARDS
Methotrexate is effective though
Corticosteroids
Biologics:
Abatacept, adalimumab, etanercept
What is the clinical syndrome that shows alongside giant cell arteritis
Polymyalgia Rheumatica
What are the symptoms of Polymyalgia Rheumatica
Abrupt stiffness and pain in proximal muscles of shoulder and/or pelvic girdle
Stiffness= worse after rest, malaise, fever, weight loss, anorexia
What are the symptoms of giant cell arterita
Localised headache, scalp tenderness, facial pain, visual symptoms (double vision, loss of vision)
What are the investigations done for giant cell arterita
Blood tests- increased erythrocyte sedimentation rate (>30mm/hr) and normocytic anaemia
Temporal artery biopsy
How do you treat giant cell arteritis or polymyalgia rheumatia?
Treated with cortiocsteorids and response is rapid
PREDNISOLONE
What is the mechanism of action of Prednisolone
Binds irreversibly to glucocorticoid receptors to prevent them from binding to steroid response elements and modifying gene expression
Modifying gene expression leads to suppression of inflammation
