Gout_Arthropathies Flashcards
- metabolic disease that most often affects middle-aged to elderly men and postmenopausal women
- results from an increased body pool of urate with
hyperuricemia - Characterized by episodic acute arthritis or chronic
arthritis caused by deposition of MSU crystals in joints and connective tissue tophi and the risk for deposition in kidney interstitium or uric acid nephrolithiasis
Gout
- most common early clinical manifestation of gout
- only one joint is affected initially, but polyarticular acute gout can occur in subsequent episodes
- The metatarsophalangeal joint of the first toe often is involved, but tarsal joints, ankles, and knees also are affected commonly
Acute arthritis
first manifestation of gouty arthritis
inflamed Heberden’s or Bouchard’s nodes
first episode of acute gouty arthritis frequently begins at ___with dramatic joint pain and swelling
night
Joints in arthritis rapidly become ___, with a clinical appearance that often mimics that of cellulitis
- warm,
- red, and
- tender
Early attacks of arthritis tend to subside
spontaneously within
3-10 days
Several events may precipitate acute gouty arthritis:
- dietary excess
- Trauma
- Surgery
- excessive ethanol ingestion
- hypouricemic therapy
- serious medical illnesses:
+ myocardial infarction
+ stroke
A proportion of gouty patients may present with a chronic nonsymmetric synovitis, causing
potential confusion with rheumatoid arthritis
Women represent only 5—20% of all patients with gout
- postmenopausal and elderly
- have osteoarthritis
- arterial hypertension that causes mild renal
insufficiency, with diuretics
presumptive diagnosis ideally should be confirmed by ___ of acutely or chronically involved joints or tophaceous deposits
needle aspiration
Present with similar clinical
features
- Acute septic arthritis,
- several of the other crystalline-associated arthropathies,
- palindromic rheumatism,
- psoriatic arthritis
seen both intracellularly and extracellularly during acute gouty attacks
needle-shaped MSU crystals
With compensated light, the needle-shaped MSU crystals are brightly
birefringent with negative elongation
In gouty arthritis, Synovial fluid leukocyte counts are
elevated from 2000 to 60,000/MI
Effusions appear ___ due to the increased numbers of leukocytes
cloudy
s of crystals occasionally produce
a thick pasty or chalky joint fluid
Excretion of___on a regular diet suggests that causes of overproduction of purine should be
considered
> 800 mg of uric acid per 24 h
Cystic changes, well-defined erosions with sclerotic
margins (often with overhanging bony edges), and
soft tissue masses
advanced chronic tophaceous gout
may aid earlier diagnosis by showing a
double contour sign overlying the articular cartilage
U/S
can show specific features establishing the presence of urate crystals
Dual-energy computed tomography (CT)
mainstay of treatment in acute attack of gouty arthritis
NSAID
Tx of gout:
- Ice pack applications and rest
- Colchicine
given as an intramuscular injection or orally for example, tapered with the resolution of the attack, can be effective in polyarticular gout
Glucocorticoids
Tx for a single joint or a few involved joints,
- intraarticular triamcinolone acetonide, 20—40 mg,
- or methylprednisolone 25-50 mg
Ultimate control of gout requires correction of the basic underlying defect:
hyperuricemia
Attempts to normalize serum uric acid to ____ to prevent recurrent gouty attacks and eliminate tophaceous deposits are critical and entail a commitment to hypouricemic regimens and medications that generally are required for life
<300-360 umol/L (5.0-6.0 mg/dL)
should be considered when hyperuricemia cannot be corrected by simple means
hypouricemic drug therapy
decision to initiate hypouricemic therapy usually is made taking into consideration the :
- number of acute attacks (urate lowering may be cost-effective after two attacks)
- serum uric acid levels (progression is more rapid in patients with serum uric acid >535 umol/L
- patient’s willingness to commit to lifelong therapy
- presence of uric acid stones
can be used in px with good renal function who underexcrete uric acid, with <600mg in a 24-h urine sample
Uricosuric agents such as probenecid
Urine volume should be maintained by ingestion of ___of water every day
1500 mL
can be started at a dose of 250 mg twice daily and
increased gradually as needed up to 3 g per day to achieve and maintain a serum uric acid level of <6mg/dL
Probenecid
generally not effective in patients with serum creatinine levels >177 umol/L (2 mg/dL)
Probenecid
Is another uricosuric drug that is more effective in
patients with chronic kidney disease
Benzbromarone
s a newer uricosuric; however, it is approved only in patients already on a xanthine oxidase inhibitor as an adjuvant at 200 mg per day
Lesinurad
- most commonly used hypouricemic agent and is the best drug to lower serum urate in overproducers, urate stone formers, and patients with renal disease
- The most serious side effects include:
- life-threatening toxic epidermal necrolysis
- systemic vasculitis
- bone marrow suppression
- granulomatous hepatitis
- renal failure
Allopurinol
40 or 80 mg once a day and does not require dose adjustment in mild to moderate renal disease
Febuxostat
- pegylated uricase, available for patients who do not tolerate or fail full doses of other treatments
- given intravenously usually at 8 mg every 2 weeks and can dramatically lower serum uric acid in up to 50% of such patients
Pegloticase
Urate-lowering drugs are generally not initiated during ____, but after the patient is stable and low-dose colchicine has been initiated to decrease the risk of the flares that often, without anti-inflammatory treatment, occur with urate lowering
acute attacks
Colchicine anti-inflammatory prophylaxis in doses of 0.6 mg one to two times daily should be given along with the hypouricemic therapy until the patient is
normouricemic and without gouty attacks for
6 months or as long as tophi are present
Should not be used in dialysis px and is given in lower doses to the px w/ renal disease or with P glycoprotein or CYP3A4 inhibitors such as clarithromycin that can incrase its toxicity
Colchicine
