Hughes Gout

What is the definition of Gout

Inflammatory response to Precipitation of monsodium urate crystals elevated by Serum Uric acid or hyperuricemia

What is pseudogout

Crystal arthritis due to calcium phosphate dihydrate deposition

What does gout present as

Acute inflammatory monoarthritis where there is inflammation in one joint with fever  and pain 

Which joints are effected by gout

Any joint of the lower extremity

What is the order of frequency of joints that are affected

Insteps

Ankles

heels

knees

wrists

fingers

elbows

What does Gout present as in older adults

Chronic polyarticular arthirits that may be condused with rhuemetoid arthriris or osteoarthiritis

Which conditions might increase Uric acid reabsorption 

Conditions that increase sodium absorption 

What medications may cause underexcretion of uric acid

Diuretics

Nicotonic acid

salicylat

ethanol

cytotoxic drugs

Cyclosporine

tacrolimus

What is the definitive diagnosis of Gout

Synovial fluid aspirate with MSU crystals in leukocytes

What is the scond choice diagnosis

Combination of monoarticular involvement of foot or ankle joint, rapid onset of severe pain and swelling and presenece of cardiovascular disease

What is the third choice diagnosis 

radiographs and ultrasounds that reveal crystal depot and tophi

What can you not rely on to diagnose Gout

Serum Uric acid because it could be normal and you still have gout

What is a key indicatior of someone who has gout

History of heart failure and they are using a diuretic and theres new pain in only one foot

What is the main risk factor of gout

Hyperuricemia and elevated serum uric acid levels

What should the baseline SUA be

less than 6 mg/dL

What are the other risk factors of gout

Diuretics

Diet of shelfish, alcohol. sugary beverages,

sedentary lifestyle 

obesity 

Older 

Male

What is the goal of treatment of Gout

To terminate attacks ASAP, reduce reccurence of attacks and reduce complications of crystal depot

What are the nonpharmacologic treatments of acute Gout

Icing joints

What is the pharmacologic treatment for acute gout

NSAIDS

Colchicine 

Corticosteroids 

Pick 1 of these asnd if it doesnt work use a combination

What is the duration that 1st line therapies for acute gout should be used

No standard duration it should be for the duration of the pain

When should you use Il-1 inhibitor

If first line therapy does not work but try all methods of corticosteroids before this

When should NSAIDS not be given to paitents

• GI bleeds, Gastritis

• Renal problems like reduced GFR

  • Cardiovasculaar- increased blood pressure and sodium/fluid retention

When should corticosteroids not be given to paitents

If theres any possibilty of infection since it can be immunosuppressing

What are the adverse effects with giving corticosteroids

• If someone has diabetes itll increase blood sugar

• GI blleds

• If someone has hypertension, fluid retention, electrolyte disturbances

When is Colcichine used 

Give as soon as possible within 24 hours of pain onset

What are the side effects of Colcichine

NVD

Neuromyopathy

Neutropenia

What IL-1 Inhibitors are given

Anakinra and Canakinumab

What type of treatment is used for Chronic gout 

Urate lowering therapy 

What are the nonpharmacologic components of Urate Lowering Therapy

• Diet to stop hypertension and to reduce serum uric acid

• Weight loss if obesse

• Review Medication List for meds that increase serum uric acid

Who do you initiate urate lowering therapy in

In people who have more that 2 acute gout attacks per year and and greater than 1 tophus

What to target when using ULT

get to a serum uric acid level of less than 6 or 5 if they have tophi or arthropathy

What is first line medication in ULT

Allopurinol and Febuxostat

What happens if it is refractory after using Allopurinol and Febuxostat

Add Uricosurics or pegloticase for severe patients

What transient risk is there when starting ULT

increased risk of acute gout flare 

What do you do treat acute gout flare with ULT

Use Colcichine, NSAID, or corticosteroid alongside Xanthine Oxidase Inhibitors

What is the dosing of Alllopurinol

Start at 100 mg then check SUA in 1-4 weeks then titrate by 100mg increments until SUA less than 6 or reached max dose of Allopurinol of 800mg

What are the rare risks of allopurinol

Allopurinol hypersensitivity syndrok 

SJS/Ten 

When is Febuxostat used

Cant use or tolerate allopurinol for whatever reason

What is the Boxed warning of febuxostat

Increased risk of cardiovascular death in paitents with gout and established cardiovascular disease

When is Probenecid used 

Added to a Xanthine Oxidase Inhibitor 

When is Pegloticase used

For very severe gout with a serum uric acid level of greater than 8

What medication is used for patients with gout and hypertension

Losartan

How to treat acute attack of pseudogout

Colcichine then NSAIDS then IA steroids and if that doesnt work short course tapering steroid