lecture 1 gout, SLE Flashcards
1
Q
Podagra
A
gout affecting the 1st MTP (big toe)
2
Q
what is gout
A
- deposition of monosodium urate crystals in joints and connective tissue
- associated with joint pain and inflammation
3
Q
what condition is associated with hyperuricemia
A
gout
4
Q
complications of gout
A
- tophi
- uric acid nephrolithiasis
- urate nephropathy
5
Q
uric acid is formed from the breakdown product of what
A
purine metabolism
- uric acid is usually secreted by the kidney
6
Q
what serum uric acid level is classified as hyperuricemia
A
>6.8 mg/dL
7
Q
people who have hyperuricemia can be broken down into what two categories
A
- uric acid overproducers (5%)
- uric acid underexcreters (95%)
8
Q
what causes uric acid overproducers; primary hyperuricemia
A
- idiopathic
- genetic disorders (rare)
9
Q
what causes uric acid overproducers; secondary hyperuricemia
A
- increased purine consumption
- malignancy
- psoriasis
- enzyme defects
10
Q
what causes uric acid underexcreters; primary hyperuricemia
A
idiopathic
11
Q
what causes uric acid underexcreters; secondary hyperuricemia
A
- decreased renal function
- metabolic acidosis
- volume depletion (dehydration)
- medications
- lead nephropathy
12
Q
triggers for acute gout attack
A
- etoh
- trauma
- medications
- loop diuretics, ASA, allopurinol
- high purine consumption
- red meat, organ meat, sardines, scallops, legumes
13
Q
name the stage: elevated uric acid levels but no sx
A
stage 1
*don’t usually need treatment
14
Q
name the stage: acute attacks of arthritis
- periods in between acute attacks-generally completely asymptomatic
A
stage 2
15
Q
name the stage: usually occurs after 10 years or more of acute attacks. in this period, the intercritical gout periods are no longer asymptomatic, the involved joints will develop chronic swelling and tophi
A
stage 3
16
Q
clinical presentation
- rapid onset (often at night)
- pain peaks w/in 8-12 hours
- severe pain, redness, warmth and swelling
- usually mono-articular
- great toe, MTP joint-most common
- knees, ankles
- can be self-limiting
- often recurrent
- tophi
A
gout
17
Q
diagnostic studies:
- joint erosion
- “rat bite” appearance
- punched out erosions
A
chronic, advanced gout
18
Q
what is the gold standard to diagnose gout
A
arthrocentesis
- needle aspiration of involved joint or tophaceous deposit
- culture and gram stain
19
Q
what findings will be present in an arthrocentesis of gout
A
- monosodium urate crystals
- negatively birefringent
20
Q
whys is serum uric acid levels not the best test for gout
A
sUA may be normal during acute attack
*most accurate >2 weeks after acute gout flare subsides
21
Q
what diagnostic study can be done to find out if a patient is an uric acid overproducer
A
check urinary uric acid over a 24 hr period
- if >800 mg on normal diet
22
Q
treatment for acute gout attack
A
- anti-inflammatory: initiate within 48 hours of onset of sx
-
NSAIDS: Indomethacin 50 mg TID (or Naproxen 500mg BID)
- discontinue NSAIDs 1-2 days after sx completely resolved
23
Q
when would you not give Indomethacin for acute gout attack
A
hx of
- pelvic ulcer disease
- GI bleed
- renal impairment
24
Q
Treatment for acute gout attack for patients who are unable to take NSAIDs
A
colchicine
initial dose 1.2mg, then 0.6 mg 1 hr later, then 0.6 mg BID until sx free
25
Treatment for acute gout attack for patients who are unable to take NSAIDs or colchicine
glucocorticoids
* oral: taper over 1-2 weeks after sx resolve
* intra-articular: r/o septic arthritis first
26
what prophylactic therapy can you give to prevent recurrent gout?
* NSAIDs
* Colchicine
* added to a urate-lowering agent
27
what are examples of urate lowering therapies
* uricosuric agents
* probenecid
* xanthine oxidase inhibitors
* allopurinol (used for long term therapy)
* febuxostat
28
If your patient has one of the following: what treatment should you give
* frequent and disabling attacks
* polyarticular gouty arthritis
* tophaceous gout
* renal stones
* prophylacis during cytotoxic therapy
* indications for urate-lowering therapy
29
the drug probenecid (uricosuric agents) is indicated for what type of gout
* underexcreters
* enhances renal excretion of uric acids
* requires good renal function
30
dosing for probenecid (uricosuric agents)
250 mg BID x 1 week (target uric acid \<6 mg/dL)
\*avoid in patients with hx of nephrolithiasis and use ASA
31
when would you give allopurinol (xanthine oxidase inhibitor)
* **agent of choice** for most patients with gout
* overproducers AND underexcreters
* decreases uric acid synthesis
32
dosing for allopurinol (xanthine oxidase inhibitor)
start at 100mg daily for a week and gradually titrate up until target range is reached
* 300mg/d adequately controls most
33
when would you give febuxostate (xanthine oxidase inhibitor)
treatment of gout in patients with mild-moderate renal insufficiency
34
why should urate lowering therapy never be used treat an acute gout attack
initiation may precipitate an acute attack
\*wait at least 2 weeks before starting treatment
35
when treating patients with gout, what condition should you be weary of
decreased renal function
* consider rheumatology referral
36
what is calcium pyrophosphate dihydrate (CPPD) deposition disease
pseudogout
37
pseudogout is primarily found in what patient population
almost 50% \> 84 yo
38
what disease is characterized by deposition of CPP crystals
pseudogout
39
what two diseases is pseudogout commonly associated with
* hemochromatosis
* hyperparathyroidism
40
clinical presentation
* acute, typically a monoarticular inflammatory arthritis
* attacks may be spontaneous or provoked by trauma or surgery
* self -limited
* joints affected
* **knees (50%)**, wrists, shoulders, feet, ankles, elbows
pseudogout
41
radiographic presentation:
* **chondrocalcinosis** (cartilage calcification)
* degenerative changes
* subchondral cysts
* osteophyte formation
pseudogout
42
what diagnostic study of synovial fluid aspiration diagnoses pseudogout
**postively birefringent CPP crystals**
43
treatment for acute pseudogout
* NSAIDs or colchicine
* colchicine 0.6 mg BID daily
* recommended if \> 3 attacks/year
44
what is systemic lupus erythematosus (SLE)
* autoimmune disorder
* autoantibodies to nuclear antigens
* multisystem disease
* female \> male
* peak incidence of disease during reproductive years
45
clinical presentation
* fever, fatigue, weight changes
* photosensitivity, alopecia, oral ulcers, **rash (malar "butterfly" and discoid)**
* arthritis (symmetric, nonerosive)
* inflammation of pericardium
* nephritis
* sz, psychosis
* CAD
* **raynaud's**
systemic lupus erythematosus
46
describe malar "butterfly" rash
fixed erythema over nasal bridge (spares nasolabial folds)
47
what is raynaud's phenomenon
* episodic vasospastic disease
* worse with cold and stress
* red, white, and blue
* 1st white (pallor)
* 2nd blue (cyanosis)
* 3rd red (erythema -following rewarming)
48
diagnostic lab testing for systemic lupus erythematosus
* ANA subtypes
* anti-dsDNA antibodies
* anti-sm (anti-smith) antibodies
49
hydroxychloroquine (Plaquenil) is used to treat what condition
antimalarials
systemic lupus erythematosus
50
give examples of cytotoxic/immunosuppressive agents you could use to treat systemic lupus erythematosus
* methotrexate
* azathioprine
51
pharmacologic treatment for systemic lupus erythematosus
* NSAIDs
* antimalarials
* corticosteroids (systemic)
52
with drug induced systemic lupus erythematosus, all patients will present with what diagnostic test
* positive antihistone antibody
53
what is Sjogren's syndrome
\*think dry
* chronic, systemic **autoimmune** disorder
* diminished exocrine gland function
54
what is the sicca complex that is associated with Sjogren's syndrome
dry eyes and mouth
55
keratoconjunctivitis sicca
dry eyes; deficiency in tear production
56
xerostomia
dry mouth
57
clinical presentation
* fatigue
* **keratoconjunctivitis sicca**
* **xerostomia**
* parotidis
* dryness of nose, throat, larynx, bronchi, vagina, and skin
* **arthritis**
* raynauds
Sjogren's syndrome
58
diagnostic evaluation for Sjogren's syndrome
* ANA
* anti-Ro/SSA
* anti-La/SSB
* schirmer's test: test for tear production
59
treatment for dry eyes associated with Sjogren's syndrome
* artificial tears
* cyclosporine drops (restasis)
60
treatment for xerostomia associated with Sjogren's syndrome
* saliva substitute (biotene OTC)
* water
61
what is systemic sclerosis
* autoimmune multisystem disorder
* diffuse **fibrosis** of skin and internal organs
62
limited cutaneous systemic sclerosis is associated with CREST syndrome. What is CREST stand for
* **C**alcinosis cutis
* **R**aynaud's phenomenon
* **E**sophageal dysmotility
* **S**clerodactyly: diffusely puffy hands
* **T**elangiectasia
\*limited to fingers, distal forearm, face and neck
63
clinical presentation
* rapid development of symmetric skin thickening
* trunk and proximal extremities
* likely to develop internal organ damage
* ischemic injury or fibrosis
* arthritis
* pulmonary HTN, fibrosis
* pericarditis, cardiomyopathy
* renal failure
diffuse cutaneous systemic sclerosis
64
diagnostic lab findings for systemic sclerosis
* **scleroderma antibody (anti-SCL-70)**
* anti-centromere antibodies (ACA): specific for limited SSc
65
treatment for cutaneous systemic sclerosis
* symptomatic and supportive
66
treatment for raynauds
nifedipine (calcium channel blocker)
67
can't see, can't pee, can't climb a tree
reactive arthritis
68
what is reactive arthritis
* inflammatory arthritis caused by GI or GU infection
* occurs predominantly in those **HLA-B27**
69
clinical presentation
* acute, asymmetric **oligoarthritis**
* often affects lower extremities
* occurs 1-4 weeks after GI or GU infection
* **conjunctivitis** (can't see)
* **urethritis** (can't pee)
* keratoderma blennorrhagicum: hyperkeratotic skin lesion on palms and soles
reactive arthritis
70
when do reactive arthritis symptoms usually resolve
6-12 months
71
genital pathogen that causes reactive arthritis
chlamydia trachomatis
72
diagnostic confirmation of reactive arthritis
HLA-B27 antigen
73
treatment for reactive arthritis
1. NSAIDs
1. indomethacin 25-50 mg TID
2. intra-articular/systemic glucocorticoids
1. if inadequate response to NSAIDs
3. sulfasalzine, methotrexate
1. if inadequate response to NSAIDs and steroids
