HYHO Gout and Pseudogout

Question 1

What gets broken down to form uric acid? How is uric acid excreted?

Answer 1

purines

sources: diet, nucleotide synthesis and metabolism

excretion: 70% kidneys, 30% gut

Question 2

What are the risk factors for gout?

Answer 2

male sex

age

obesity

HTN

hyperlipidemia

CVD

meds

diet

lead exposure

Question 3

What are the two routes of hyperuricemia?

Answer 3

overproduction - hepatic metabolism, cell turnover

underexcretion - kidneys > gut; main cause in most pts

Question 4

When is maximal pain felt for acute gouty flares?

Answer 4

within first 24 hrs

acute flares: often begin overnight, most commonly affects 1st MTP, knee, or ankle joints

Question 5

What factors provoke a gout flare?

Answer 5

ETOH

trauma

inflammatory states (infection, surgery, MI…)

dehydration

Question 6

___ is a definitive test for gout.

Answer 6

arthrocentesis of the affected joint’s synovial fluid

samples should be sent for cell count, culture, gram stain

needle shaped, negatively birefrigent crystals

Question 7

What tests can support a gout dx?

Answer 7

serum uric acid level increase

CBC with diff (r/o septic arthritis)

Question 8

When is an X-ray useful in gout dx?

Answer 8

chronic gout pts only –> may reveal bony erosions

“punched out lesions”

“overhanging edge”

X-ray is NOT helpful in acute gouty flaires

Question 9

How do you treat acute vs. chronic gout?

Answer 9

acute: NSAIDs, colchicine, glucocorticoids
chronic: allopurinol, febuxostat, probenecid, lesinurad, uricase

Question 10

In a pt with CKD, what treatment for gout may be preferred?

Answer 10

acute - glucocorticoids

NSAIDs and colchicine use should be used with caution

Question 11

What medication used to treat HTN has some uricosuric effects?

Answer 11

Losartan

Question 12

What is pseudogout?

Answer 12

• deposition of calcium pyrophosphate (CPP) crystals in and on cartilaginous surfaces
• can provoke an acute inflammatory arthritis clinically similar to gout

pathophys isn’t know, but pyrophosphate produced by chondrocytes likely precipitates with calcium forming CPP crystals which then activate inflammatory pathways leading to an acute arthritic attack

Question 13

Risk factors for pseudogout include…

Answer 13

Age > 60

OA

hyperparathyroidism

hemochromatosis

hypophosphatasia

hypomagnesemia

Question 14

Clinically, what is a difference between gout and pseudogout?

Answer 14

pseudogout acute attacks can last weeks to months

Question 15

What is the definitive test for pseudogout?

Answer 15

arthrocentesis of affected joint’s synovial fluid

CPP cyrstals: rhomboid shaped, positively birefringent under polarized light

Question 16

What is the treatment for pseudogout?

Answer 16

NSAIDs

Colchicine

Intra-articular glucocorticoid injection or oral prednisone

Treat underlying disease

Question 17

What are the autonomic innervation levels of the kidneys, UE, and LE?

Answer 17

Kidneys: SNS T10-11, PNS Vagus

UE: SNS T2-7

LE: SNS T11-L2

Question 18

What is the 5 model approach to gout?

Answer 18

biomechanical: OMT for SD

resp/circ: lymphatic OMT

neuro: OMT to normalize SNS/PNS

met/en/immune: arthrocentesis, uric acid levels, renal function/med doses, caution with systemic steroids in DM pts, consider stopping thiazides

behavior: diet changes, avoid alc