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rheumatology > gout and pseudo > Flashcards

gout and pseudo Flashcards

1
Q

what is a typical presentation of gout

A

acute swelling and erythema of the 1st metatarsal-phalangeal joint (podagra)

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2
Q

what age group and gender is gout usually seen in

A

middle aged males

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3
Q

what criteria can be used for a less typical presentation of gout

A

the Neijmegen criteria

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4
Q

what is required for a definitive diagnosis of gout

A

requires the identification of urate crystals in synovial fluid in joints or from trophi

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5
Q

what is a tophus

A

a deposit of uric acid crystals in the form of of monosodium urate

  • appear as chalky white deposits and are markers of severe disease
  • typically in digits or over the elbows
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6
Q

what causes gout

A

excess uric acid in the blood stream or hyperuricaemia leads to deposits that then leads to inflammation

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7
Q

what is a typical history of gout

A
  • usually history of an attack in past year if 2nd time
  • severe pain usually in a single joint (monoathritis)
  • acute onset (<24hours often overnight) with episodes lasting 1-2 weeks
  • 1st MTPJ, foot or ankle but can involve any joint
  • axial skeleton and proximal joints rarely involved
  • self limiting 5-14 days
  • max severity 2-6 hours
  • synovitis, swelling and erythema
  • fever, malaise and confusion
  • puruitus(itch) and desquammation skin shedding
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8
Q

how will joints feel on examination with gout

A

tender, hot red and swollen

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9
Q

what diagnosis needs to be excluded with gout

A

septic athritis

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10
Q

what are the 3 main diff diagnosis

A
  1. septic arthritis
  2. pseudo-gout secondary to chonodrocalcinosis
  3. psoriatic arthritis
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11
Q

what investigations are there for gout 4

A
  • baseline renal and liver function
  • convalescent serum urate (4-6 weeks after attack as low during attack)
  • x-ray of symptomatic joint (erosions in established disease)
  • screen patient for cardiovascular RF
  • Synovial aspirate usually not performed in primary care
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12
Q

what are the 7 criteria for the nijmegen criteria and what number is needed to be certain of gout

A

-male 2
-previous reported arthritis attack 2
-onset within 1 day
-joint redness
-first metatarsophalangeal joint involvement 2.5
-hypertension or >1 cardiovascular disease
-serum uric acid >0.35 mmol/l
need greater than 8 point

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13
Q

why is serum urate lower during an attack

A

in 50% of patients will have normal levels due to a direct effect of inflammation on urate excretion

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14
Q

how long should you wait for serum urate measurement after an attack

A

4-6 weeks

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15
Q

what other condition though has elevated urate levels

A

severe psoriasis

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16
Q

what drug should be used when initiating or increasing the dose of a ULT and why

A
  1. colchicine 500mcg BD which if tolerated and required increase to max QID
    - used as prophylaxis against acute attacks secondary to ULT therapy
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17
Q

when should colchicine be reduced and what is it contraindicated in

A

side effects of diarrhoea and colic occur

  • renal or hepatic failed
  • P-glycoprotein inhibitor eg verapamil, cyclosporin
  • CYP3A4 inhibitor vir, mycin and azole
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18
Q

what is the prophylactic treatment dosage of colchicine and how long can it be used

A

2x daily
500mg
up to 6 months

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19
Q

when should urate lowering therapy be offered 4

A
  1. in patients with trophi
  2. recurrent attack >2 attacks/yr
  3. renal impairment
  4. diuretics
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20
Q

what level of serum urate should be aimed for, but what level for long term mainentance

A

<0.3 mmol/l but for long term mainentance below 0.36 are adequate

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21
Q

management of gout

A
  1. low dose NSAID
  2. local ice packs
  3. oral colchicine
  4. joint aspiration
  5. ult
  6. lifestyle
22
Q

what is the first line urate lowering agent for gout and how should it be titrated and what does the patient need to be told
how does it work

A

allopurinol
xanthine oxidase inhibitor
-start at a low dose and titrate upwards every 4 weeks until uric acid is <0.3
- remind patients that allopurinol may increase the risk of acute attacks of gout just after initiating treatment and some weeks after
BUT THEY should not stop their allopurinol
-can be given with colchicine to reduce risk

23
Q

what is the second line therapy to allopurinol for ULT, what needs to be checked, and how should it be given dosage

A

febuxostat

  • check liver function test prior to initiation
  • start at a low dose and increase after 4 weeks if sua is still >0.3
24
Q

what prior history may indicate potential hypersensitivity to febuxostat

A
  • hypersensitivity to allopurinol

- renal disease

25
Q

what is hyperuricaemia defined as

A

2 standard deviations above the mean population

26
Q

what pathway catalyses to uric acid

A

xanthine oxidase catalyses the end of conversion of hypoxanthine to xanthine and then to uric acid

27
Q

what is the main abnormality causing gout

A

90% of patients the main abnormality is reduced uric acid excretion by renal tubules due to impaired response to a purine load

28
Q

how is uric acid excreted

A

1/3 by the gut and 2/3 by the kidneys

29
Q

what gene regulates uric acid excretion in the kidneys

A

SLC2A9

30
Q

inflammatory pathway in gout and septic arthritis

A
  1. Cellular debris, LPS and uric acid crystal all signal through NLRP3 inflammasome nod like receptor 3
  2. Cytoplasmic protein complex within monocyte/ macro lead to IL1 secrete
  3. Rapid recruit neutrophils
  4. Switches off after week or so
31
Q

3 causes of gout

A
  1. reduced renal excretion
  2. increased production of uric acid
  3. increased intake
32
Q

what causes reduced renal excretion of uric acid 6

A
  1. increased renal tubular absorb
    2.renal failure
  2. lead toxicity and immunosuppressants (tacrolimus and cyclosporin)
  3. lactic acidosis
    5.alcohol (increase purine catabolism in liver so increase lactic acid blocks excretion)
    6.drugs
    thiazide diuretics
    low dose asprin
    cyclosporin
    pyrazinamide
33
Q

what 3 foods are high in uric acid

A

red meat
seafood
offal

34
Q

what 5 things cause over production of uric acid

A
  1. myeloproliferative and lymphpro.. disease
  2. psoriasis
  3. high fructose intake
  4. glycogen storage disease
  5. inherited disorders
    - Lesch-Nyhan syndrome (HPRT mutation)
    - Phosphoribosyl pyrophosphate synthetase 1 mutation
35
Q

risk factors for gout

A
  • metabolic syndrome
  • high alcohol intake (guanosine from beer)
  • generalised OA
  • diet high in fructose, red meat, low in vit d or coffee
  • lead poisoning (saturnine gout)
36
Q

how does OA increase the risk of gout

A

reduction in proteoglycan levels and other inhibitors of crystal formation

37
Q

what is Lesch Nyhan syndrome

A

x linked recessive

assoc. to mental retardation, self-mutilation, choreoathetosis

38
Q

main diff dx of gout

A 
septic arthritis
infective cellulitis
reactive arthritis
psoriatic arthritis
pseudo-gout
39
Q

will gout re-occur?

A
  • usually presents as one joint and then can attack another joint a few days later= cluster attacks
  • in most a second attach occurs in a year
  • but can lead to chronic attack
  • risk of renal failure
40
Q

complications of gout

A

infection from trophi
renal failure
renal stone formation

41
Q

investigations for gout

A
  1. aspiration of urate crystals
    - increased turbidity and >90% neutrophils
  2. biochemical screen due to metabolic syndrome risk
    - renal function
    - uric acid
    - glucose
    - lipid profile
    - esr, crp, neutrophilia
  3. x-ray erosions in trophaceous gout
42
Q

normal uric acid levels

A

<0.3

43
Q

dosage for allopurinol titration 2 categories

A

-start at 100mcg or 50mcg in elderly or renal impairment
-increase by 100mcg ever 4 weeks (50mcg in elderly/ renal)
until max dose 900mcg or SE occur

44
Q

dosage of allopurinol when on azathioprine

A

1/4 of dosage as inhibits XO so prolongs the activation

45
Q

side effects of febuxostat

A
  • increased risk of gout flare up as more effective than allopurinol at reducing uric acid so higher risk
46
Q

when is febuxostat CI

A

not in severe renal failure creatinine clearance <30ml/min

47
Q

dosage of febuxostat

A

up to 120mcg

start 80mcg daily

48
Q

what is pseudogout

A

calcium pyrophosphate dihydrate crystal deposition into joints

49
Q

risk factor for chondrocalcinosis

A 
age
oa
primary hyperparathyroid
familial
haemochromtotis
hypophosphatasia
50
Q

symptoms pseudogout

A 
acute inflammatory arthritis
warm
tender
erythematous joint
fever
commonly knee
trigger factors include trauma, illness 
can get chronic arthropathic
51
Q

investigation of pseudogout

A

joint aspiration: cppd crystals which are rhomboid
x-ray joint
raised pyrophosphate levels

52
Q

management of pseudogout

A

joint aspiration

-steroids, colchicine or nsaids

rheumatology (9 decks)

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