Gout in Primary Care Flashcards
hyperurisemia can be primary or secondary. Secondary can be?
to disease
- lymphoproliferative disorders ,
- psoriasis
- CHF
- CKD
Drugs
- thiazide
- furosemide
- aspirin
- teriparatide
Common causes include
- CKD, Alcohol, dehydration, preeclampsia, myeloproliferative disorder, chemotherapy
managment of asymptomatic hyperuircemia?
- no treatment with urate lowering agent except: persistant hyperuircemia in the infrequent patients with sustained serum urate concentrations
clinical stages of gout?
- acute gouty arthritis
- intercritical (or interval) gout
- chronic recurrent and tophaceous gout
- severe, sudden disabling
- maximum intensity by 12-24 hours
- predilection to lower extremity
- days to weeks than resolves
acute attack
predisposing/triggering factors for gout?
- trauma
- surgery
- starvation
- fatty foods and other dietary overindulgence
- dehydration
- ingestion of drugs affecting (raising or lowering) serum urate concentrations- allopurinol, uricosuric agents, thiazide or loop diuretics) and low-dose aspirin may all promote gouty attacks
clinical diagnosis of gout?
male sex (2 points)
previous patient-reported arthritis attack (2 points)
onset within one day (0.5 points)
joint redness (1 point)
first metatarsal phalangeal joint involvement (2.5 points)
hypertension or at least one cardiovascular disease (1.5 points)
serum uric acid level greater than 5.88mg/dL (3.5 points)
- patient is asymptomatic between gout attacks
- most patient will have a second attack if untreated (62% in 2 years)
- patient might end up with chronic tophaceous gout if untreated
intercritical gout
treatment of acute attacks?
- NSAIDs
- COX 2 inhibitors
- colchicine if NSAIDs are contraindicated or for patient who used colchicine successfully in the past
- prednisone 30-50mg and taper over 10 days
- intra-articular steroids if 1-2 joints are affected and infection has been ruled out
renal complications of hyperuricemia?
- renal stones
- chronic urate nephropathy
indications of urate lowering therapy?
- recurrent gouty attacks that disturbs patient life or schedule
- tophaceous gout
- renal stones when uric acid is the culprit
- very high uric acid levles
- urate nephropathy
- tumor lysis syndrome
goal is to lower uric acid to below 6mg/dl
- Start with 100mg daily when renal function is above 40
- increase dose slowly to reach the target
- side effects: rash, leukopenia or thrombocytopenia, diarrhea and drug fever
allopurinol
An umbrella term that refers to a spectrum of clincical manifestations that happen because of the deposition of CPP crystals in the cartilage of affected joints
Calcium pyrophosphate deposition disease
clinical manifestations of CPPD?
- asymptomatic disease
- pseudo gout
- pseudo-rheumatoid arthritis
- pseduo-osteoarthrits, with or without superimposed acute attacks
- pseudo-neuropathic joint disease
- most patients
- some will report minor joint symptosm or signs by accurate H&P: wrist symptoms and knee abnormality by exam (genu varus)
asymptomatic form
- self-limited acute or subacute attacks of arthritis involving only one or several extremity joints
- occasionally associated with systemic symptoms: fever, leucocytois
- KNEES, wrist, shoulders..others
pseduogout
