Gout
Reports last weekend family wedding w/ lots of partying eating, and drinking ETOH - Right great toe MTP inflamed, tender to touch, red, restricted ROM. No other joint abnormalities * What do you suspect? Diff?
- Gout (Podagra: first metatarsalphalangeal involvement): Bursitis, Septic arthritis, Cellulitis, CA, fracture, trauma, RA,
Gout attacks - what initiates the attack? - crystal deposition usually occurs in CENTRAL/ PERIPHERAL areas of the body - Repeat attacks lead to ACUTE ARTHRITIS/ CHRONIC ARTHRITIS--> formation of what?
- usually occur when monosodium urate crstals precipitate in the joint & initiate the inflammatory response - Crystal deposition: usually occurs in peripheral areas of the body - repeat attacks: lead to acute arthritis than chronic arthritis & formation of tophi
All of the following are true concerning treatment of gout except A. Serum uric acid-lowering agents should be started immediately after the first attack B. Allopurinol can cause a sensitivity reaction with rash and fever C. Uricosuric drugs require intake of large quantities of fluid D. Colchicine can be given to reduce recurrence of gout symptoms
A- ANSWER: probenecil & allopurinol & uloric - do not start at the first attack. no long term attack (if they ever do.) b: true - rash & fever: main s/e of allopurinol c: true - uricosuric drugs: they all need large fluid d: colchicine- can be chronic medication for gout to reduce gout symptoms
The most appropriate first line treatment for an acute gout flare is (assuming no kidney disease or elevated bleeding risk): A. Indomethacin 50mg TID for 2 days; then 25 mg TID for 3 days B. Doxycycline 100mg BID for 5 days C. Prednisolone 35mg QD for 5 days D. Ice therapy
A. (prednisolone: not recommended initially although clinically seen... not used for firstline therapy. EBT says if Colchicin, Indocin doesn't work, then you can try prednisone)
Usual presentation of gout
Acute extremely painful Monoarticular attack
Drug treatments of gout - Chronic gout meds (MOA, dosing)
Allopurinol - inhibits uric acid production - 50-300mg/ day based on renal function Probenicid - increases uric acid excretion - 250mg~1000mg PO BID according to serum uric acid & kidney function
Physical examination of Gout
Assess joints: MTP, Distal joints Acute stage joint: Effused, warm, red, tender Chronic gout: Large, painless nodules = aka TOPHI
* Management plan?
Colcichin - dosing: 1.2mg at onset and then another 0.6mg 2 hrs later NSAIDs (mainstay acute gouty attack) - Indomethacin: 25mg- 50mg BID (no more than 5 -10 days at a time, very harsh on stomach) - Naproxen: 750mg BID, but 500mg BID back off
M vs F Age
Men (disease of men) usually 40-60 yo (usually after age 60)
Drug treatments of GOUT - Acute attack
NSAID: symptomatic relief Colchicine PO: acute flare - dosing: 1.2mg at onset and then another 0.6mg 2 hrs later
Do you stop Colchicin when pt c/o diarrhea?
No. this new guideline is based on diarrhea in mind
Diet treatment what to avoid?
Organ meats Cold cuts Wine Beer Oily fish shell fish Peas Beans Spinach mushrooms
If conservative & first line tx fails?
Refer to Rheumatology for prescription of febuxostat & something new
Gout risk factors
organ meats obesity high purine diets dehydration/ starvation Paget's disease Diuretics hypothyroidism hyperparathyroidism (Beer & Crab)
New drug used to treat gout - Krystexxa (________________)
Krystexxa (pegloticase) = IV therapy - lowers uric acid level & reduces deposits of uric acid crystals in the joints and body tissues - indicated for hard to treat gout in patients who failed previous treatments - Black box warning: allergic reaction 1/4 in clinical trials
72 yr old dx of gout. long hx of CHD. most likely contributing factor to the development of gout in this older female is? a. lead intoxication b. illegal whiskey c. binge eating d. thiazide diuretics
Thiazide diuretics
New drug used to treat gout - febuxostat (_____________) - MOA - usage
Uloric (febuxostat) : highly potent non-purine selective inhibitor of xanthine oxidase - lowers concentration of uric acid in the blood of gout pts w/ hyperuricemia
What happens with Gout?
Undersecretion of uric acid (less of oversecretion of uric acid)
68 yo male wc/o "my toe is killing me, what is this?" right great toe, red, swollen, last night feeling tired & has chill. PMH: HTN, - HCTZ, GERD- Zantac No Sx Walks exercise 2-3 times a week 15 30 min what other information do you require? what is it imporatant to cover in the physical exam?
When did it start? any previous attacks? life style in the past few days? Trauma? - the affected toe
Treatment of Gout
Diet Weight loss Hydration Balance diet & eating schedule
Which joints are usually affected by gout?
Great toe (50%) ankle & knee next sites
The best method (definitive method) of verifying a diagnosis of gout in a joint is which of the following: A. Radiographic examinatino of the joint with two views B. Ultrasound C. Palpation D. Joint aspiration ***********TEST*******
D. Joint aspiration - only way to definitevely dx gout: looking for uric acid crystals
Drug induced Gout - Medications causing hyperuricemia?
Diuretics Salicylates Niacin Cyclosporine Levodopa
What can elevate uric acid levles?
ETOH Diuretics Uric acid is + in 90% of cases, many be normal at time of acute attack
Pathophysiology of gout (primary) Reason for gout attack
Enzyme defects --> 1) overproduction of uric acid 2) inadequate elimination of uric acid by the kidney or BOTH Reason: usually unknown
What is the medical term for first metatarsalphalangeal involvement?
Podagra
Diagnosing gout
Presentation synovial fluid analysis Radiographics (when classic erosive joint changes) Uric acid levels
History taking - Gout
Previous attacks? Diet: organ meats, wine, beer, oily fish, shellfish, peas, beans, spinach, mushrooms Dehydration (can trigger attack) esp after hospitalization (NPO) Starvation: plasma uric acid rise
What is more common? Primary vs. Secondary gout
Secondary gout - related to diet, dehydration, lack of exercise , and other risk factors