Question | Answer |
Gout epi | M 40-50 yo; F 65 yo; genetic, environmental |
Gout risk factors | infxn; trauma; wt loss (esp extreme diets); hosp; dyslipidemia (esp trigs) |
Causes of hyperuricemia: overproduction | Nutritional (purine consumption, EtOH); hematopoietic, psoriasis, drugs |
Causes of hyperuricemia: underexcretion | Nutritional (EtOH); renal / vasc; drugs (diuretics); metab / hormones |
Sx of hyperuricemia | usu asymptomatic / req no tx; look for underlying cause (HTN, metab syn) |
uric acid levels influenced by: | body habitus, ETOH use, BP, diet & insulin resistance |
4 stages of gout | hyperuricemia, acute gout, intercritical, chronic |
Hyperuricemia = uric acid level: | >6.8 mg/dL (levels inc at puberty; higher in men) |
High uric acid levels also assoc with: | HTN, metab syn, CAD, CKD |
Gout: monoarticular manifestn | 1st MTP (podagra)> instep > heel > ankle > knee; LE>UE; very painful; self limiting |
Gout clinical manifestations | very sudden; affected jt = warm, dusky red, swollen, exquisitely tender; systemic signs possible |
Gout hard to distinguish from: | septic arthritis |
Gout: Not useful in dx: | serum uric acid, plain films |
Gold standard in dx of gout | joint aspirate demonstrating uric acid crystals |
Tx of choice: acute gout | NSAIDs (indomethacin, celecoxib) |
Acute gout: other tx | colchicine (esp for prophylaxis); c’steroids (oral, IV, intra-art) for pt who cannot take NSAIDs; |
Gout tx: never … | start a drug to tx elevated uric acid in midst of acute attack; don’t stop prophylactic tx (if already on it) during acute; tx arthritis first, then hyperuricemia (not both at once) |
Gout prophylaxis | Lifestyle mods (limit offending foods, ETOH; increased fluid intake; wt loss); Eval for provoking meds (diuretics); aspirin, niacin |
Indications for gout prophylaxis: | 2 or more attacks/yr; erosive dz on plain film; uric acid nephropathy/ nephrolithiasis; chronic polyarticular gout |
gout prophylaxis: Pharmacology: | colchicine; uricosurics (probenecid); xanthine oxidase inhibitors (allopurinol, Uloric) |
uricosurics: MOA | decrease urate reabsorption, promotes excretion |
xanthine oxidase inhibitors: MOA | decrease serum uric acid levels |
prior to starting prophylaxis for acute gout: | do 24 hr urinary uric acid (<800mg/d = undersecretion; >800mg/d = overproducer) |
Acute gout prophylaxis: other | limit (3-12 mo); d/c when pt at goal (<6 mg/dL uric a. x 3-6 mo & no attacks); poss fenofibrate, losartan, vit C |
genetically engineered uricase = | Krystexxa : reduces uric acid & melts tophi; for severe chronic refractory gout |
intercritical gout | freq inc w/time in untx’d pts; subsequent attacks: less sudden, polyarticular, slower to resolve |
Hallmarks of Chronic Tophaceous Gout | destructive polyarticular dz; resemble other forms arthritis; multi tophaceous deposits (tophi) (hands, feet, helix of ear); dev about 12 yr after 1st attack; dir rel to uric a. levels; no pain-free intercritical pd |
Chronic Tophaceous Gout: tx | probenecid, allopurinol, steroids |
CPPD Epi | true prevalence unk (F > M); if FH, usu presentation <50 yo |
CPPD etio | idiopathic or associated with primary dz (hyperPTH, hypothyroid, hemochromatosis, hypophosphatemia) |
CPPD risk factors | trauma (can be minor), MI, CVA, infxn, surg (knee arthroscopy, ?intra-art hyaluronate) |
CPPD clin presentation: if sx: | If sx, varies: can mimic RA, OA, gout; post-traumatic hemarthrosis; systemic illness (pseudo-PMR); axial dz (c-spine stenosis) |
CPPD clin presentation: sudden onset | (sim to gout); systemic sx (fever, chills, inc acute phase reactants); acute poss in setting of chronic arthropathy; may worsen OA when both exist |
CPPD dx | demo crystals in jt fluid; chondrocalcinosis on plain film; CT, MRI and U/S all detect CPPD; do serum Ca, Mg, PO4, alk phos, ferritin, Fe, TIBC |
CPPD tx | Tx underlying dz; no spec tx for idiopathic dz; poss: NSAIDs / celecoxib; c’steroids (IV, po, intra-art); LD colchicine; hydroxychloroquine; arthrocentesis |
BCP crystals have a predilection for: | the shoulder |
BCP clinical presentations: | calcific tendinitis; Milwaukee shoulder; subacromial bursitis; knee & hip poss; |
BCP tx | NSAIDS, physical therapy |
Calcific tendonitis: | 4t/5t decades; DM (esp ins-dept); deposits in rotator cuff; often resolve spont |
Milwaukee shoulder: | rare arthropathy (usu elderly women); rapid rotator cuff & GHJ destn; assoc w/ lg hematomas, bloody synovial fluid |
CPPD fx where: | large joints (knee, wrist, elbow); chondrocalcinosis; also MCPs, hips, shoulders, ankles |