Rheum Pt One- Paulson Flashcards
- Hyperuricemia (increased uric acid levels)
- Recurring attacks of acute arthritis (painful)
- Tophi (deposits of monosodium urate monohydrate crystals) under skin
- Renal dz
- Uric acid nephrolithiasis
- Chronic deforming arthritis
Are all signs of what disease?
Gout
90% of those with primary gout are men or women?
Men around age 40-60
When do women typically get gout?
Women after 60 (after estrogen decreases)
What two things can put people at risk for gout?
alcohol & obesity
What can be oddly protective in gout?
milk
A middle-aged obese man without a healthy diet comes in with a very painful big toe. What is the most likely dx?
gout
What foods promote hyperuricemia?
red meat, seafood, fructose (think the kings disease)
What medications can put you at risk for gout?
Thiazide & loop diuretics, low dose ASA
What serum urate level is a sign of gout?
> 6.8 mg/dL
Uric acid imbalance can also cause what which can lead to gout?
Renal insufficiency, acidosis, volume depletion/dehydration, lead exposure
What are the 3 stages of gout?
- Acute gouty arthritis
- Intercritical (interval) gout
- Chronic articular and tophaceous gout
“my big toe hurts,” sudden night onset, painful and tender, swollen joints, red and warm, fever, and within 12-24 hours constitutes what type of gout?
- Acute gouty arthritis
- Intercritical (interval) gout
- Chronic articular and tophaceous gout
- Acute gouty arthritis
Acute gouty arthritis mc causes swollen, very tender, red and warm overlying skin where on the body?
MTP of great toe is classic. Called “podagra”
Is gout symmetrical or asymmetrical?
Asymmetrical
Do tophi typically occur in the beginning of gout or later in the course of gout?
Later on in course of gout
Irregular, asymmetric macroscopic deposits of urate are ________
tophi
Tophi=pathognomonic for gout
If you think a patient has a tophi, should you do an I & D?
NO
Gout can also cause major problems with which organ system?
Renal.
Can cause: uric acid nephrolithiasis (urate deposits and forms kidney stones), chronic urate nephropathy (when crystals are in deposited in the kidneys) and acute renal failure (because when uric acid gets stuck in collecting ducts and ureters)
How do you diagnose gout?
Aspirate for synovial fluid and send for microscopy
Aspirate for synovial fluid would show _________ in gout
monosodium urate crystals
This interp would be from what test? and what type of gout?
“negatively birefringent”, needle-like, when viewed with polarized light microscopy
Aspirate for synovial fluid
Gout, not pseudogout
When would you get a U/S or CT for gout?
if later on in the disease and kidney problems
You would see “rat bite lesions” in gout later on on what type of imaging?
Radiographs
What labs may be elevated in someone with gout?
- Elevated serum uric acid (elevated during an attack) but can also be low, normal, or high- don’t be fooled!
- Elevated WBC
- Elevated ESR/CRP
If asymptomatic hyperuricemia, should we treat?
No. Monitor, watch, wait
What lifestyle modifications can help reduce risk of gout?
– Lose weight
– Reduce alcohol consumption
– Reduce purine-rich food consumption
– Drink enough fluids to urinate ≥2L per day
• Avoid hyperuricemic meds, if possible
The goal of gout tx is to ________
Relieve pain as quickly as possible.
This medication doesn’t help in acute gout attacks but can be used longterm
Allopurinol
Urate-lowering meds (ie: allopurinol) don’t help in acute attacks- don’t start one during acute attack
What medications are used for acute gout attacks?
NSAIDs= 1st choice (Naproxen, Indomethacin)
Colchicine
Corticosteroids
If a patient has an NSAID intolerance, what is a good alternative for acute gout attacks?
Colchicine
Do start low and go slow with colchicine or start high and taper?
Start high and taper
Day 1: 1.2 mg initially, then 0.6 mg 1 hour later. Day 2 and onward:0.6 mg QD-BID until 2-3 days after symptoms have resolved.
What are two mc side effects of colchicine?
Diarrhea and abd cramping
This form of acute gout tx is good for people who can’t take NSAIDs or colchicine
Corticosteroids “ones”
– Intra-articular injection: triamcinolone 40 mg (large joint), 30 mg for a medium joint, or 10 mg for a
small joint
– Oral: prednisone 40-60 mg/day tapered over 7 days
– IV: methylprednisolone 40 mg/day tapered over 7 days
– IM: triamcinolone 40-60 mg. May need to repeat 1-2x.
If taking a corticosteroid, use caution for what diseases?
CHF, glucose intolerance, poorly controlled HTN
Once you start a gout med do you have to take it for life?
Yes
Once treating gout, the goal is to achieve a serum urate level of what?
<6 mg/dL
– Slowly (not more than 1-2 mg/dL/month)
T/F: Use low-dose prophylactic colchicine (or low-dose NSAID) when initiating antihyperuricemic therapy to reduce risk for acute flare
True do this until in the asymptomatic period (2 wks)
These medications reduce gout production and are used long-term for gout- not used for attacks
Xanthine Oxidase Inhibitors (XOI) (allopurinol and febuxostat)
When initiating allopurinol, what should you also give prophylactically?
Give prophylactic colchicine when initiating
This is a last of the line med for gout and is not to be given in patients with G6PD
Probenecid (URICOSURIC med)
– Patient must have normal renal function (CrCl>60)
– Urinate at least 2L/day to avoid precipitation of uric acid in urinary tract
This gout med is for patients who have been refractory to all other therapies and also contraindicated in pts with G6P deficiency
Pegloticase (URICASE med)
This disease is also known as calcium pyrophosphate dihydrate (CPPD or CPP) deposition disease
Pseudogout
A radiograph for pseudogout would show what?
Chondrocalcinosis
– Radiographic evidence of calcification in articular cartilage
Most of the time, pseudogout is ________
Idiopathic
In ______________ gout, – You may see CPP deposition in a joint on a radiograph but have no symptoms
Asymptomatic/incidental
In _____________, there are self-limited, sudden attacks of pain, redness, warmth, disability, and swelling, monoarticular or
oligoarticula
Acute arthritis/pseudogout
What joint is mc affected in pseudogout?
Knee
Trauma can cause this, even surgery
This type of pseudogout can minic RA
Chronic CPP crystal inflammatory arthritis(“pseudo-RA”)
This type of pseudogout mimmacks OA
OA with CPPD (“pseudo-OA”)
This type of pseudogout is like a charcot joint and is from severe joint degeneration from CPP crystal deposition
Pseudo-neuropathic joint disease
How do you dx pseudogout?
Joint aspirate
What type of crystals are diagnostic in pseudogout?
CPP crystals in joint aspirate are diagnostic
“weakly positively birefringent rhomboid crystals” by polarized light microscopy should make you think of what disease?
Pseudogout
What are the 4 treatments for acute pseudogout?
-Aspiration then intraarticular glucocorticoid injection
• Triamcinolone
– NSAIDs
• Indomethacin, naproxen, salicylates
– Colchicine
– Systemic corticosteroids (oral,IV,orIM)
How do you treat OA with CPPD?
Treat like OA
How do you treat pseudo-neuropathic joint disease (like charcot foot)
Treat like charcot arthropathy
T/F you can have gout and pseudogout at the same time
FALSE
When should you prophylaxis someone with pseugout? And what is the prophylaxis?
Consider if the patient has ≥ 3 attacks per year
Colchicine
What is pseudo-RA prophylaxis?
– NSAIDs 1st choice (use lowest dose possible)
• Naproxen
• Indomethacin
– Alternatives if NSAIDs ineffective
• Colchicine 0.6 mg QD or BID
• Hydroxychloroquine
• Low-dose glucocorticoids ie: prednisone (up to 10 mg /day)
*If all else fails, sometimes methotrexate works.
Are tophi present in pseudogout?
No
Does gout or pseudogout mc affect large joints and knees and wrists?
Psuedogout
Crystals called Needle shaped and strongly negative birefringent should make you think of what?
Gout
Crystals called Small, rhomboid shaped or irregular and weakly positive birefringent should make you think of what?
Pseudogout
What medications can affect urate balance, specifically underexcretion of uric acid?
Thiazide diuretics (HCTZ), ASA, loop diuretics (lasix, furosemide)
