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CC Sept 2017 Gout

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echoecho's version from 2017-10-01 17:14

Section

Question Answer
What is gout?an inflammatory arthropathy resulting from preciptation of MSU (monosodium urate) crystals in the joint space (can also accumulate in bones, cartilage, tendons and bursae)
What is chronic gout?gouty attacks are recurrent, resulting in chronic gout (associated with accumulation s of urate deposits called tophi)
How many Americans are affected by gout?8 million
List the risk factors of gout?older age, male, black race, diminished renal function, obesity
What diets are high in purines?red meats, organ meats, purine-riche seafoods (sardines, shellfish), high-fructose corn syrup, alcoholic beverages (especially beer)
List the medications associated with increased risk of gout?thiazide, loop diuretics, lower doses of ASA (81-325 mg), high dose niacin, Levodopa, Cyclosporine, Losartan, Atorvastatin, Bactrim, igher doses of ASA 91-2 g/day)
How does acute gout present?as a mooarticular arthritis of sudden onset, associated with redness, swelling and pain
Which joint is commonly affected?metatarsophalangeal (MTP) joint
List conditions that mimic gout?infectious arthritis, calcium pyrophosphate deposition disease, rheumatoid arthritis, OA, psoriatic arthritis
Is an elevated uric acid level necessary for the dx of acute gout?no
List the diagnostic criteria for acute gout developed by the American College of Rheumatology?1) presence of monosodium urate (MSU) crystals in joint fluid AND/OR 2) presence of tophus known to have MSU crystals AND/OR 3) presence of 6 of the following = 1)more than 1 attack of acute arthritis 2) development of maximal inflammation within 1 day 3) attack of monoarticular arthritis 4) observation of joint erythema 5) pain or swelling of the first MTP 6) unilateral attack involving the first MTP 7) unilateral attack involving the tarsal joint 8) suspected tophus 9) hyperuricemia 10) asymmetric swelling within a joint on x-ray 11) subcortical cyst without erosion on x-ray 12) negative culture of joint fluid for microorganisms during an acute attack
*** Both the ACR (2015) and the American College of Physicians (ACP) give strong recommendations for the use of what medications for gout?NSAIDS, oral colchicine, systemic corticosteroids
Are all options equally effective?yes
What therapy is an option for severe cases with polyarticular or large joint involvement?combination therapy
Comment on NSAIDs use in gout?1) should be given at maximum dosing 2) continued until acute attack has resolved 3) NSAIDS have analgesic and anti-inflammatory properties 4) side effects of NSAIDS are renal injury, GI bleed and cardiovascular complications
Comment on Colchicine use in gout?1) low-dose (1.2 mg followed by 0.6 mg 1 hour later OR 0.6 mg every 8 hours) is as effective as higher doses recommended in the past (1.2 mg followed by 0.6 mg hourly x 6 hours) 2) has a lower risk of GI bleeding
What type of patients should not use colchicine?renal or hepatic insufficiency patients
Comment on corticosteroid use in gout?1) it is an option for those who can't tolerate NSAIDs or colchicine. 2) 40-60 mg /day x 5-10 days OR 2-5 days followed by tapering over 7-10 days 3) intra-articular steroids are an option if large joints are involved
What can be applied to the affected joint to relieve pain but does not affect swelling?ice
What education should be given the patient with gout?1) change medications that cause gout 2) dietary modifications 3) alcohol moderation 4) weight management
*** What is the new thinking about urate-lowering therapy (long term)?since there is uncertain benefit over the long term and potential adverse effects, the ACP recommends that urate lowering therapy NOT be initiated for most patients with first gout attack or for those with infrequent attacks
*** List the 4 indications by the American College of Rheumatology indications for urate lowering therapy?Established dx of gouty arthritis AND 1) tophus or tophi by clinical exam of radiography 2) frequent attacks of acute gouty arthritis (> 2 per year) 3) chronic kidney disease stage 2 or worse 4) past urolithiasis
What are the first line recommendations of urate-lowering therapy (xanthine oxidative inhibitors)?1) allopurinol (Zyloprim) 2) febuxostat (Uloric)
What are the side effects of Allopurinol?rash (potential fatal hypersensitivity reaction is more likely in Asian patients)
What are the side effects of Febuxostat?1) GI 2) musculoskeletal pain
Comment on Probenecid?1) a uricosuric agent 2) an option for patients who underexcrete uric acid and have normal renal function 3) delay ULT until 2 weeks after resolution of the acute attack
Since initiation of ULT is associated with a flare of acute gouty symptoms, what can be used?colchicine prophylaxis (0.6 mg once or twice a day) OR low-dose NSAIDS (Naproxen 250 mg BID) is recommended along with the ULT
When is colchicine discontinued?when the patient is asymptomatic for 6 months and tophi have resolved
What medications are a second-line option for gout if other meds are contraindicated or not tolerated?oral corticosteroids
If the patient has no symptoms of gout while on ULT and prophylaxis, duration of prophylactic therapy is ____ months after achieving target uric acid level in an individual without tophi or ____ months after attaining goal uric acid (if > 1 tophi are noted on exam)?3; 6
Should patients with ongoing symptoms of gout remain on prophylaxis?yes
*** The goal of urate lowering therapy (ULT) is uric acid level < _____ to ____ mg/dL. Levels , _____ mg/dL may be necessary to improve gout signs and symptoms?5 to 6; 5
Intensification of therapy by doing what may be necessary if the uric acid goal is not achieved?maximizing dose, addition of probenecid to a xanthine oxidative inhibitors such as Allopurinol or Febuxostat
Should ULT be continued indefinitely along with other lifestyle measures and interventions?yes
*** SUMMARY = Define gout?an inflammatory arthropathy caused by precipitation of monosodium urate crystals in joints and other tissues
*** SUMMARY = List risk factors?1) dietary excess 2) alcohol consumption 3) some medications
*** SUMMARY = List recommended interventions for an acute gout attack?1) colchicine 2) maximum dose NSAIDs 3) corticosteroids
*** SUMMARY = Urate-lowering therapy (ULT) is NOT recommended for what?1) first gouty attack or 2) infrequent attacks
*** SUMMARY = What is the goal of ULT for uric acid levels?< 5-6 mg/dL
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