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CM2 Exam 2 > Rheum Pt One- Paulson > Flashcards

Rheum Pt One- Paulson Flashcards

1
Q
  • 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?

A

Gout

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2
Q

90% of those with primary gout are men or women?

A

Men around age 40-60

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3
Q

When do women typically get gout?

A

Women after 60 (after estrogen decreases)

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4
Q

What two things can put people at risk for gout?

A

alcohol & obesity

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5
Q

What can be oddly protective in gout?

A

milk

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6
Q

A middle-aged obese man without a healthy diet comes in with a very painful big toe. What is the most likely dx?

A

gout

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7
Q

What foods promote hyperuricemia?

A

red meat, seafood, fructose (think the kings disease)

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8
Q

What medications can put you at risk for gout?

A

Thiazide & loop diuretics, low dose ASA

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9
Q

What serum urate level is a sign of gout?

A

> 6.8 mg/dL

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10
Q

Uric acid imbalance can also cause what which can lead to gout?

A

Renal insufficiency, acidosis, volume depletion/dehydration, lead exposure

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11
Q

What are the 3 stages of gout?

A
  1. Acute gouty arthritis
  2. Intercritical (interval) gout
  3. Chronic articular and tophaceous gout
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12
Q

“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?

  1. Acute gouty arthritis
  2. Intercritical (interval) gout
  3. Chronic articular and tophaceous gout
A
  1. Acute gouty arthritis
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13
Q

Acute gouty arthritis mc causes swollen, very tender, red and warm overlying skin where on the body?

A

MTP of great toe is classic. Called “podagra”

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14
Q

Is gout symmetrical or asymmetrical?

A

Asymmetrical

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15
Q

Do tophi typically occur in the beginning of gout or later in the course of gout?

A

Later on in course of gout

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16
Q

Irregular, asymmetric macroscopic deposits of urate are ________

A

tophi

Tophi=pathognomonic for gout

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17
Q

If you think a patient has a tophi, should you do an I & D?

A

NO

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18
Q

Gout can also cause major problems with which organ system?

A

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)

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19
Q

How do you diagnose gout?

A

Aspirate for synovial fluid and send for microscopy

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20
Q

Aspirate for synovial fluid would show _________ in gout

A

monosodium urate crystals

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21
Q

This interp would be from what test? and what type of gout?

“negatively birefringent”, needle-like, when viewed with polarized light microscopy

A

Aspirate for synovial fluid

Gout, not pseudogout

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22
Q

When would you get a U/S or CT for gout?

A

if later on in the disease and kidney problems

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23
Q

You would see “rat bite lesions” in gout later on on what type of imaging?

A

Radiographs

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24
Q

What labs may be elevated in someone with gout?

A
  1. Elevated serum uric acid (elevated during an attack) but can also be low, normal, or high- don’t be fooled!
  2. Elevated WBC
  3. Elevated ESR/CRP
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25
Q

If asymptomatic hyperuricemia, should we treat?

A

No. Monitor, watch, wait

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26
Q

What lifestyle modifications can help reduce risk of gout?

A

– Lose weight
– Reduce alcohol consumption
– Reduce purine-rich food consumption
– Drink enough fluids to urinate ≥2L per day

• Avoid hyperuricemic meds, if possible

27
Q

The goal of gout tx is to ________

A

Relieve pain as quickly as possible.

28
Q

This medication doesn’t help in acute gout attacks but can be used longterm

A

Allopurinol

Urate-lowering meds (ie: allopurinol) don’t help in acute attacks- don’t start one during acute attack

29
Q

What medications are used for acute gout attacks?

A

NSAIDs= 1st choice (Naproxen, Indomethacin)

Colchicine

Corticosteroids

30
Q

If a patient has an NSAID intolerance, what is a good alternative for acute gout attacks?

A

Colchicine

31
Q

Do start low and go slow with colchicine or start high and taper?

A

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.

32
Q

What are two mc side effects of colchicine?

A

Diarrhea and abd cramping

33
Q

This form of acute gout tx is good for people who can’t take NSAIDs or colchicine

A

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.

34
Q

If taking a corticosteroid, use caution for what diseases?

A

CHF, glucose intolerance, poorly controlled HTN

35
Q

Once you start a gout med do you have to take it for life?

A

Yes

36
Q

Once treating gout, the goal is to achieve a serum urate level of what?

A

<6 mg/dL

– Slowly (not more than 1-2 mg/dL/month)

37
Q

T/F: Use low-dose prophylactic colchicine (or low-dose NSAID) when initiating antihyperuricemic therapy to reduce risk for acute flare

A

True do this until in the asymptomatic period (2 wks)

38
Q

These medications reduce gout production and are used long-term for gout- not used for attacks

A

Xanthine Oxidase Inhibitors (XOI) (allopurinol and febuxostat)

39
Q

When initiating allopurinol, what should you also give prophylactically?

A

Give prophylactic colchicine when initiating

40
Q

This is a last of the line med for gout and is not to be given in patients with G6PD

A

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

41
Q

This gout med is for patients who have been refractory to all other therapies and also contraindicated in pts with G6P deficiency

A

Pegloticase (URICASE med)

42
Q

This disease is also known as calcium pyrophosphate dihydrate (CPPD or CPP) deposition disease

A

Pseudogout

43
Q

A radiograph for pseudogout would show what?

A

Chondrocalcinosis

– Radiographic evidence of calcification in articular cartilage

44
Q

Most of the time, pseudogout is ________

A

Idiopathic

45
Q

In ______________ gout, – You may see CPP deposition in a joint on a radiograph but have no symptoms

A

Asymptomatic/incidental

46
Q

In _____________, there are self-limited, sudden attacks of pain, redness, warmth, disability, and swelling, monoarticular or
oligoarticula

A

Acute arthritis/pseudogout

47
Q

What joint is mc affected in pseudogout?

A

Knee

Trauma can cause this, even surgery

48
Q

This type of pseudogout can minic RA

A

Chronic CPP crystal inflammatory arthritis(“pseudo-RA”)

49
Q

This type of pseudogout mimmacks OA

A

OA with CPPD (“pseudo-OA”)

50
Q

This type of pseudogout is like a charcot joint and is from severe joint degeneration from CPP crystal deposition

A

Pseudo-neuropathic joint disease

51
Q

How do you dx pseudogout?

A

Joint aspirate

52
Q

What type of crystals are diagnostic in pseudogout?

A

CPP crystals in joint aspirate are diagnostic

53
Q

“weakly positively birefringent rhomboid crystals” by polarized light microscopy should make you think of what disease?

A

Pseudogout

54
Q

What are the 4 treatments for acute pseudogout?

A

-Aspiration then intraarticular glucocorticoid injection
• Triamcinolone

– NSAIDs
• Indomethacin, naproxen, salicylates

– Colchicine

– Systemic corticosteroids (oral,IV,orIM)

55
Q

How do you treat OA with CPPD?

A

Treat like OA

56
Q

How do you treat pseudo-neuropathic joint disease (like charcot foot)

A

Treat like charcot arthropathy

57
Q

T/F you can have gout and pseudogout at the same time

A

FALSE

58
Q

When should you prophylaxis someone with pseugout? And what is the prophylaxis?

A

Consider if the patient has ≥ 3 attacks per year

Colchicine

59
Q

What is pseudo-RA prophylaxis?

A

– 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.

60
Q

Are tophi present in pseudogout?

A

No

61
Q

Does gout or pseudogout mc affect large joints and knees and wrists?

A

Psuedogout

62
Q

Crystals called Needle shaped and strongly negative birefringent should make you think of what?

A

Gout

63
Q

Crystals called Small, rhomboid shaped or irregular and weakly positive birefringent should make you think of what?

A

Pseudogout

64
Q

What medications can affect urate balance, specifically underexcretion of uric acid?

A

Thiazide diuretics (HCTZ), ASA, loop diuretics (lasix, furosemide)

CM2 Exam 2 (8 decks)

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