Transcript Gouty Arthritis

PA Days Presentation
Brian K. Shrawder, PA-S
LHU
Patient of the Day
51 y/o Caucasian male, swollen, red, painful MTP
joint. Started last night; Pain – sharp/stabbing;
exacerbated with anything touching; No relief
Hx: MI ~ 2 months ago; medications – thiazide
diuretics for B/P; ~30 12oz beers / weekend;
father had this condition.
Denies recent trauma, infections, penetrations or
constitutional symptoms.
Patient of the Day
What’s in your differential?
1.
2.
3.
4.
Gout***
Calcium Pyrophaosphate “Pseduo-gout”
Calcium Apatite
Septic Joint
Gout: Background
• “Disease of Kings”
• Found exclusively in Humans, Birds &
Dalmatian canines
• Heterogeneous disease including:
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Elevated serum urate concentration (hyperuricemia)
Reoccurring attacks of monosodium urate monohydrate crystals
Deposits of monosodium urate crystals (TOPHI)
Renal disease of glomerular, tubular, interstitial tissues & blood vessels
Uric acid nephrolithiasis
Gout: Background
• Occurs with HYPERURICEMIA – elevations
above 7 mg/dl (men) or 6 mg/dl (women).
• Deposits in superstaturations joints or kidneys
Gout: Epidemiology
• Rates: 2.3 -> 41.3% of ‘normal’ population
• Factors: higher serum BUN, Creatinine, body
wt, ht, age, B/P, & ETOH
• “Body Bulk” -> estimated bw, surface area, or
BMI most important predictors of hyperuricemia
Gout: Epidemiology
• At puberty, serum urate concentrations increase
~ 1-2 mg/dl & sustained
• Females, lower changes until menopause
(estrogen)
• Urate levels > 9 mg/dl – incidences highest
rates
Gout: Clinical Features
• 4 stages:
– Asymptomatic Hyperuricemia
– Acute gouty arthritis
– Intercritical gout
– Chronic tophaceous
Gout: Clinical Features
1. Asymptomatic Hyperuricema
– Serum urate elevated, but no manifestations
– Tendency increases with elevated levels
– This phase ends with first attack (stone or arthritis)
– First attack, occurs after AT LEAST 20 years of
sustained
Gout: Clinical Features
2. Acute Gouty Arthritis:
– 40 -> 60 years (men) & > 60 (females)
– Onset BEFORE 25 -> enzymatic defect due to
overproduction purine, renal disorder or
cyclosporine use
– 1st MCP site = #1
– ‘works way up to foot’
– Explosive onset after falling asleep ‘well’
– Joint: Hot, red, dusky, swelling, extremely painful
Gout: Clinical Features
2. Acute Gouty Arthritis (continued)
– Precipitating factors: anti-hyperuricemic therapy,
diuretics, IV heparin & cyclosprine
– Also: trauma, infection, ‘foreign protein’ therapy,
hemorrhage, radiographic contrast
Gout: Clinical Features
• Diagnosis:
– Aspiration of joint
– Inspections of fluid
• Needle shaped, negative birefringence (CUB)
– Clinical features of GOUT:
• Max inflammation w/in 1 day, one joint, red, swelling,
painful, hyperuricemia, asymmetical
Gout: Clinical Features
3. Intercritical Gout:
– “interval gout” – periods between attacks
– Some may never have 2nd attack
– 62% within first yr, 11% 2 – 5 yrs, 4% 5-10yrs
– Later attacks, less explosive onset, polyarticular,
more severe, last longer, abate more gradually
Gout: Clinical Features
4. Chronic Tophaceous Gout:
– Polararticular gout with no pain free intervals
– Correlations with degree and duration of
hyperuricemia
– Irregular, asymmetrical nodules
– Destructions of joints, grotesque deformities,
progressive to crippling
– Skin overlying may ulcerate: extrude a white, chalky
or pasty material composed of urate crystals
Gout: Abortive Treatment
1) Colchicine: .5 mg/hr until
• Joint symptoms ease
• N/V/D
• Maximum 10 doses
– Preferred for unconfirmed dx
– NSAIDs preferred with secure dx
Gout: Abortive Treatment
2) NSAIDs (Indomethacin – DOC) 50 – 75 mg every 4 – 8
hours until 200 mg total
3) Glucocorticoids – Intra-articular injections;
useful in limited joint treatment
4) *Prophylaxis – (colchicine) anti-inflammatory
2 weeks use prior anti-hyperuricemia therapy
Gout: Preventative Treatment
Hyperuricemia – control uric acid levels < 6 mg/dl
(a) Xanthine oxidase inhibitors (allopurinal) – ‘over
producers’
*block production of uric acid
*pass > 700 mg/day
(b) Uricosuric agents (Probenecid) – ‘under excretory’
*enhance renal excretion of uric acid
Thanks
Any Questions?
References:
Cush, John, Kavanaugh, Arthur, Stein, Michael. (2005) Rheumatology: Diagnosis & Therapuetics.
Lippincott, Williams & Willkins
Hang-Korng, Ea MD. (2006) Gout: Update on Some Pathogenic and Clinical Aspects. Rheumatic
Diseases Clinics of North America. 32, (2) 295 – 311
Harris, Edward D., et al. (2005) Kelley’s Textbook of Rheumatology. Philadelphia: Elsevier
Science.
Nuki, George MB. (2006) Treatment of Crystal Arthropathy – History and Advances. Rheumatic
Diseases Clinics of North America. 32 (2), 333-357
Rakel, Robert MD, Bope, Edward MD (2007) Conn’s Current Therapy. Philadelphia: Saunders
Elsevier.