Gouty Arthritis

Question 1

What is gout?

Answer 1

a metabolic disease of a heterogeneous nature, often familial, associated with abnormal amounts of urates in the body and characterized early by a recurring acute arthritis, usually monoarticular, and later by chronic deforming arthritis.

Question 2

Associated hyperuricemia (serum uric acid > 6.8) is due to what?

Answer 2

An overproduction or underexcretion of uric acid

Question 3

Gout is most common in what type of population?

Answer 3

Pacific Islanders (Filipinos and Samoans)

Question 4

What are the 2 types of gout?

Answer 4

• primary

- secondary

Question 5

What is primary gout linked to?

Answer 5

Several genes, making it hereditary

Question 6

What is secondary gout linked to?

Answer 6

Acquired causes of hyperuricemia, such as medications, myeloproliferative disorders, multiple myeloma, hypothyroidism, etc.

Question 7

Ingestion of what promotes hyperuricemia?

Answer 7

alcohol

Question 8

What type of patients often suffer attacks of gout? Why?

Answer 8

Hospitalized patients, because of changes in diet, fluid intake, or medications

Question 9

About __% of patients with primary gout are men

Answer 9

90

Question 10

When does gout onset typically occur in women?

Answer 10

postmenopausal

Question 11

What is the characteristic nodular deposition of monosodium urate monohydrate crystals with an associated foreign body reaction called?

Answer 11

the tophus

Question 12

What is acute inflammation of gout believed to be initiated by?

Answer 12

the ingestion of uncoated urate crystals by monocytes and synoviocytes

Question 13

What are important factors in precipitating acute gout?

Answer 13

Rapid fluctuations in serum urate levels, either increasing or decreasing

Question 14

What is characteristic of chronic stage gout?

Answer 14

Tophaceous invasion of the surrounding tissue, with structural derangement and secondary degeneration (OA)

Question 15

Uric acid kidney stones are present in -% of patients with gouty arthritis

Answer 15

5-10

Question 16

What causes chronic urate nephropathy?

Answer 16

the deposition of monosodium urate crystals in the renal medulla and pyramids

Question 17

What are the signs and symptoms of acute gouty arthritis?

Answer 17

• Sudden in onset
• Nocturnal
• More than one joint may be involved
• Involved joints are swollen and exquisitely tender
• Fever

Question 18

Which joint is the most susceptible to gouty arthritis?

Answer 18

MTP joint of the great toe (“podagra”)

Question 19

Where can tophi be found?

Answer 19

• external ears
• feet
• olecranon
• prepatellar bursa
• hands

Question 20

Gout can evolve into chronic polyarthritis of upper and lower extremities that mimics what disease?

Answer 20

rheumatoid arthritis

Question 21

A single uric acid determination during an acute flare of gout is normal in up to __% of patients. Therefore a normal serum uric acid level does not exclude gout.

Answer 21

25

Question 22

Sodium urate crystals in joint fluid or material aspirated from a tophus are ____ shaped and _____ bifringent.

Answer 22

needle

negative

Question 23

What are the differential diagnoses associated with acute gout?

Answer 23

• Cellulitis
• Pyogenic arthritis
• Pseudogout

Question 24

What is the differential diagnosis associated with chronic gout?

Answer 24

Chronic rheumatoid arthritis

Question 25

How should asymptomatic hyperuricemia be treated?

Answer 25

it should not be treated

Question 26

How should an acute attack of gouty arthritis be treated?

Answer 26

- NSAIDS (Indomethacin and Naproxen) - Colchicine - Corticosteroids - Interleukin-1 inhibitors

Question 27

What is the goal of treatment between gouty arthritis attacks?

Answer 27

Minimize urate deposition in tissues, which causes chronic tophaceous arthritis, and to reduce the frequency and severity of recurrences

Question 28

What individuals are more likely to benefit from pharmacological treatment?

Answer 28

- Mild chronic kidney disease - Multiple and frequent attacks of gout - Higher uric acid level - Tophaceous gout

Question 29

Patients should avoid ___-purine diets

Answer 29

high

Question 30

True or False Thiazide and loop diuretics, niacin, and aspirin should be avoided in patients with gout

Answer 30

True

Question 31

What are the 2 indications for daily administration of colchicine?

Answer 31

- For individuals with mild hyperuricemia and only occasional attacks of gout - When urate-lowering therapy is started

Question 32

What are the 3 indications for urate-lowering therapy?

Answer 32

- frequent acute arthritis (two or more episodes per year) - tophaceous deposits - chronic kidney disease (stage 2 or worse)

Question 33

The goal of urate-lowering therapy is to maintain the serum uric acid at or below _ mg/dL

Answer 33

6

Question 34

What are the 3 classes of agents that can be used to lower the serum uric acid?

Answer 34

- Xanthine oxidase inhibitors - Uricosuric agents - Uricase

Question 35

What are the 2 xanthine oxidase inhibitors?

Answer 35

Allopurinol and febuxostat

Question 36

How do allopurinol and febuxostat lower plasma uric acid levels?

Answer 36

By blocking the final enzymatic steps in the production of uric acid

Question 37

What is the most frequent adverse effect of allopurinol?

Answer 37

precipitation of an acute gouty attack

Question 38

What is the most frequent adverse effect of febuxostat?

Answer 38

abnormal liver tests

Question 39

How do uricosuric agents | lower plasma uric acid levels?

Answer 39

by blocking the tubular reabsorption of filtered urate, thereby increasing uric acid excretion by the kidney

Question 40

What is the uricosuric agent of choice in the US?

Answer 40

Probenecid

Question 41

What are the contraindications of Probenecid?

Answer 41

- patients with a creatinine clearance < 50 mL/min - history of nephrolithiasis (uric acid or calcium stones) - overproduction of uric acid (>800 mg in 24 hours)

Question 42

What is the uricase enzyme that must be administered IV?

Answer 42

Pegloticase

Question 43

Why do hyperuricemia and gout tend to develop in transplant patients?

Answer 43

because they have decreased kidney function and require drugs that inhibit uric acid excretion