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PCM IV Final > HYHO: Gout and Pseudogout > Flashcards

HYHO: Gout and Pseudogout Flashcards

1
Q

Purines

A

PUR-DOUBLE-AG

  1. Adenine
  2. Guanine
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2
Q

Pyrimidine

A
  1. Cytosine (DNA)
  2. Thymine (DNA)
  3. Uracil (RNA)
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3
Q

How is uric acid formed in the body?

A

Degradation of purines (A,G) => produces uric acid.

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4
Q

Degradation pathway that forms uric acid

A

Inosine => hypoxanthine => xanthine => uric acid

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5
Q

What enzyme catalyzes the final 2 reactions in the formation of uric acid?

A

Xanthine oxidase

  1. Hypoxanthine => Xanthine via XO
  2. Xanthine => uric acid via XO.
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6
Q

Humans source of purines

A
  1. Diet

2. Nucleotide synthesis and breakdown

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7
Q

How do we excrete/get rid of uric acid?

A
  1. Kidneys (70%) via pee

2. Gut (30%) via poop

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8
Q

Too much uric acid can form what

A

MSU crystals

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9
Q

What is gout?

A

Intermittent painful, inflammatory joint attacks, in response to uric acid crystals due to hyperuricemia

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10
Q

RF for gout

A
  1. Males
  2. Older ppl
  3. Pacific islander
  4. HTN/hyperlipidemia/CV disease
  5. CKD
  6. Meds: Thiazides
  7. Diet (alcohol and red meat)
  8. Lead
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11
Q

Why is gout MC in men than women?

A

Estrogen increases the excretion of uric acid, making it less common in premenopausal W.

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12
Q

What meds increase risk of gout?

A

Thiazides

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13
Q

What foods/drinks increase risk of diet?

A

Alcohol and red meat

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14
Q

_______ = uric acid deposition in tissue

A

Gouty tophi

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15
Q

Hyperuricemia is due to what?

A
  1. Overproduction (hepatic metabolism and cell turnover)

2. Underexcretion (from mostly kidneys)

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16
Q

What is the main cause of hyperuricemia?

A

Underexcretion

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17
Q

Clinical presentation of gout

A
  1. Acute onset joint pain, most painful in 1st 24 hours that often begin at night.
  2. Joint = swollen, painful red and warm
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18
Q

Gout is MC in what joints?

A
  1. 1st MTP (podegra)
  2. Knee
  3. Ankle
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19
Q

Provoking factors for gout flare

A
  1. Alcohol
  2. Trauma
  3. Inflammatory states (infection, surgery, MI)
  4. Dehydration
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20
Q

Definitive diagnosis of gout

A

Arthrocentesis of joint’s synovial fluid

Send sample for: cell count, culture, and gram stain

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21
Q

_________ is used to look for monosodium urate crystals, which are
needle shaped, _____ birefringent crystals

A

Polarized light microscopy

negatively birefringent crystals

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22
Q

Other labs to diagnose gout

A
  1. Serum uric acid level

2. CBC with differential (to R/O septic arthritis: has L shit)

23
Q

When are XR useful for patients with gout?

A

In chronic gout, to look for bony erosions (punched out lesions or overhanging edge)

NOT useful for acute flares

24
Q

MSU crystals they appear ____ when parallel to the axis of the polarized field and ____ when perpendicular to the axis

A

Yellow = parallel

Blue = perpendicular

25
Q

Calcium pyrophosphate crystals are rhomboid, pale, and weakly (not as vividly) ______ birefringent; they appear _____ when parallel to the axis and _____ when perpendicular.

A

Weakly positively birefringent

Blue = parallel

Yellow = perpendicular

26
Q

Non-inflammatory arthritis has synovial fluid with ______ WBCs/μL

-Typically d/t?

A

< 2,000

Mechanical or degenerative disorder (Osteoarthritis)

27
Q

Inflammatory arthritis has synovial fluid with ______ WBCs/μL

-Typically d/t?

A

> 2,000

AI (RA, spondylarthritis, ankylosing, psoriatic arthritis), infection or crystal-induced

28
Q

Infectious (septic) arthritis has synovial fluid typically with ________ WBCs/μL

What helps differentiate this etiology from others?

A

> 20,000 - 50,000

Gram stain and fluid culture

29
Q

Crystal-induced fluid can vary but typically has between ________ WBCs/μL

Typically d/t?

A

10,000-50,000

Gout or pseudogout

30
Q

Treatment of

Acute Gouty Flare

A
  • Untreated gout will resolve within days to weeks (but it will be a very painful period)
    1. NSAIDS (Indomethacin, Naproxen, etc…)
  1. Colchicine (inhibits cytoskeletal function of neutrophils preventing activation and
    migration of neutrophils)
  2. Glucocorticoids (oral Prednisone or intra-articular/IM steroid injection)
    - May be preferred treatment option in patients with CKD
31
Q

When treating patients with gout and chronic kidney disease (CKD), what medications should you avoid? What should you use instead?

A

Avoid = NSAIDS and colchicine

Instead, use oral steroids or intra-articular steroids.

32
Q

Treatment of

Chronic Gout

A
  1. XO inhibitors (Allopurinol or Febuxostat)
  2. Uricosuric agents (Probenecid and Lesinurad)
  3. Uricase (Pegloticase)
33
Q

What medication should you NOT give during a acute flare of gout, because it cause another one?

A

XO inhibitors (Allopurinol and Febuxostat): wait 2 weeks after flare

34
Q

MOA of uricase drugs (Pegloticase)

A

Humans lack uricase which converts uric acid into highly soluble allantoin.

35
Q

PEARL: What drug used to treat HTN also has uricosuric effects?

A

Losartan

36
Q

If patient has SEVERE gout and if all other treatments have failed, what is the last resort?

A

Pegloticase

37
Q

Goal serum uric acid level:

A

< 6.0 mg/dL in patients without tophi

< 5.0 mg/dL in patients with tophi

38
Q

Prevent gout measures

A

Avoid of factors that cause hyperuricemia:

  1. Red meat
  2. Seafood
  3. Alcohol
  4. High-fructose corn syrup beverages
39
Q

What is pseudogout?

A

Deposition of calcium pyrophosphate (CPP) crystals in and on cartilaginous surfaces that can
provoke an acute inflammatory arthritis, similar to gout

40
Q

RF for pseudogout

A
  1. Age > 60
  2. OA
  3. Metabolic diseases:
    (Hyperparathyroidism, hemochromatosis, hypophosphatasia (rare genetic disease), hypomagnesemia)
41
Q

Pseudogout clinical presentation

A
  1. Asymptomatic to symptomatic
  2. Monoarticular or oligoarticular arthritis
  3. Joint is typically swollen, erythematous, warm, and painful
    - fever can also be seen
42
Q

Pseudogout MC affects what joints?

A
  1. Knee
  2. Wrist
  3. Rarely the 1st MTP joint
43
Q

How is pseudogout different from acute gouty flare in how long it lasts?

A

Acute attacks of CPPD
disease = weeks to months

Regular gout = days - 1 week

44
Q

-Provoking factors for Pseudogout flares

A
  1. Surgery

2. Acute illness

45
Q

Definitive diagnosis of pseudogout

A

Arthrocentesis of synovial fluid

-Polarized light microscopy is used to look for CPP crystals,

46
Q

Can XR be used to dx pseudogout?

A

No, but can support it by finding chondrocalcinosis (cartilage calcification, but not specific)

47
Q

Treatment of pseudogout

A
  1. NSAIDS
  2. Colchicine
  3. Intra-articular glucocorticoid injection or oral prednisone
  4. Treat underlying metabolic disease if present
48
Q

ANS innervation to kidney

A

Sympathetics: T10-11
Parasympathetic: Vagus N (OA,AA)

49
Q

ANS innervation to UE and LE

A

UE: T2-7
LE: T11-L2

50
Q

Respiratory/circulatory for gout

A

lymphatic OMT

51
Q

Neurologic for gout

A

OMT to NL sympathetics and parasympathetics

52
Q

Metabolic/NRGTIC/immune for gout patient

A
  1. Do Arthrocentesis for acute gout flare to confirm dx.
  2. Assess uric acid levels
  3. Assess renal function and renal dose medications as needed (i.e. NSAIDs,
    Colchicine, and allopurinol)
  4. Caution with systemic steroid use in diabetics (may need to check glucose more
    frequently or give insulin temporarily)
  5. Consider stopping Thiazide if recurrent gout (Thiazides raise uric acid levels)
53
Q

Caution with systemic steroid use in who? and why?

A

Diabetics: may need to check glucose more often or give insulin temporarily

54
Q

Behavioral for gout patient

A

Avoid red meats, seafood and alcohol

PCM IV Final (6 decks)

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