Rheum week 1 - hot, painful, swollen joint Flashcards
Give 4 possible causes of a hot swollen joint …
- septic arthritis always consider as most inportant
- gout / pseudogout
- reactive arthritis
- psoriatic arthritis
What do tophi look like ?
little growths - almost like keloids on the ear
like white balls under the skin on finger pads
What nail changes do you expect to see in psoriatic arthritis ?
- nail pitting (like needle pinpricks all over)
- oncholysis (areas where the nail has lifted from the nail bed - looks the same as the whit email off the end of finger just in the middle/connected to white)
What are tophi indicative of ?
gout
What are some risks factors for gout ?
- male
- overweight
- high alcohol intake
- high purine intake (e.g steak, oily fish, marmite, beans)
- diuretics
- metabolic syndromes (diabetes, HTN)
What is the gold standard investigation to help diagnose gout ?
joint aspiration and synovial fluid analysis
What investigations need to be done if gout is suspected ?
- joint aspiration and analysis
others:
- FBC rule out septic
- blood cultures rule out septic
- U+Es and LFTs influence meds
- CRP and ESR inflammatory markers, monitor treatment response
When should rheumatoid factor and CCP antibody testing be done?
if RA is a differential diagnosis
can XR be used to diagnose/assess acute gout?
no!
- XR may show damage due to chronic gout
- XR is useful in cases of pseudo gout
What is the treatment of gout ?
- patient education
- rest, elevate and cool affected joint
- NSAIDs at highest dose e.g naproxen (consider PPI for gastric protection)
- oral colchicine
- steroid injection can use IV or oral steroids if injection isn’t appropriate
which medication is best for treating symptoms of acute gout?
NSAIDs (e.g naproxen) or colchicine
NSAIDs - highest dose available
Colchicine - 500 micrograms BD
When is Colchicine prescribed to treat gout?
in acute cases, where patients cannot be prescribed NSAIDs
What drug treatment is offered to patients who experience recurrent episodes of gout to prevent future attacks ?
urate-lowering therapy (ULT)
allopurinol
When can you start allopurinol to prevent future gout attacks ?
at least 2 weeks after acute gout has settled otherwise it can flare the gout back up
What drug can you give to prevent future gout attacks that also act to decrease tophi?
allopurinol
What is a common side effect of colchicine?
diarrhoea
What can trigger gout?
- purine high diet
- alcohol
- diuretic use
- injury
- dehydration
- inflammation
- haemolytic anaemias
- blood cancers
- renal failure
What can trigger gout?
- purine high diet
- alcohol
- diuretic use
- injury
- dehydration
- inflammation
- haemolytic anaemias
- blood cancers
- renal failure
What drug is used as urate-lowering therapy in patients who cannot take allopurinol ?
febuxostat
Describe gout to a patient …
- gout is caused by a build up of uric acid in a joint.
- uric acid comes from breakdown of a compound called purine which is found in most foods.
- usually the kidneys get rid of most of the uric acid in urine, but some gets cycled back to the body.
- therefore a build up of uric acid is caused by either taking in too much purine (food) or not getting rid of enough (kidneys)
Does another gout attack while on allopurinol and naproxen/colchicine mean that the treatment isn’t working ?
no!
it is relatively common for patients to experience attacks do gout up to 12 months after starting treatment
What changes would you see on XR in established gout ?
juxta-articular erosions
What is the most appropriate initial treatment of gout?
Naproxen and a PPI
or straight to colchicine if patient can’t take NSAIDs or has tried ibuprofen and doesn’t feel it’s working
How does allopurinol work ?
takes uric acid from soft tissue and into blood for excretion via kidneys
