Gout_Arthropathies

Question 1

• metabolic disease that most often affects middle-aged to elderly men and postmenopausal women
• results from an increased body pool of urate with
  hyperuricemia
• Characterized by episodic acute arthritis or chronic
  arthritis caused by deposition of MSU crystals in joints and connective tissue tophi and the risk for deposition in kidney interstitium or uric acid nephrolithiasis

Answer 1

Gout

Question 2

• most common early clinical manifestation of gout
• only one joint is affected initially, but polyarticular acute gout can occur in subsequent episodes
• The metatarsophalangeal joint of the first toe often is involved, but tarsal joints, ankles, and knees also are affected commonly

Answer 2

Acute arthritis

Question 3

first manifestation of gouty arthritis

Answer 3

inflamed Heberden’s or Bouchard’s nodes

Question 4

first episode of acute gouty arthritis frequently begins at ___with dramatic joint pain and swelling

Answer 4

night

Question 5

Joints in arthritis rapidly become ___, with a clinical appearance that often mimics that of cellulitis

Answer 5

• warm,
• red, and
• tender

Question 6

Early attacks of arthritis tend to subside
spontaneously within

Answer 6

3-10 days

Question 7

Several events may precipitate acute gouty arthritis:

Answer 7

• dietary excess
• Trauma
• Surgery
• excessive ethanol ingestion
• hypouricemic therapy
• serious medical illnesses:
  + myocardial infarction
  + stroke

Question 8

A proportion of gouty patients may present with a chronic nonsymmetric synovitis, causing

Answer 8

potential confusion with rheumatoid arthritis

Question 9

Women represent only 5—20% of all patients with gout

Answer 9

• postmenopausal and elderly
• have osteoarthritis
• arterial hypertension that causes mild renal
  insufficiency, with diuretics

Question 10

presumptive diagnosis ideally should be confirmed by ___ of acutely or chronically involved joints or tophaceous deposits

Answer 10

needle aspiration

Question 11

Present with similar clinical
features

Answer 11

• Acute septic arthritis,
• several of the other crystalline-associated arthropathies,
• palindromic rheumatism,
• psoriatic arthritis

Question 12

seen both intracellularly and extracellularly during acute gouty attacks

Answer 12

needle-shaped MSU crystals

Question 13

With compensated light, the needle-shaped MSU crystals are brightly

Answer 13

birefringent with negative elongation

Question 14

In gouty arthritis, Synovial fluid leukocyte counts are

Answer 14

elevated from 2000 to 60,000/MI

Question 15

Effusions appear ___ due to the increased numbers of leukocytes

Answer 15

cloudy

Question 16

s of crystals occasionally produce

Answer 16

a thick pasty or chalky joint fluid

Question 17

Excretion of___on a regular diet suggests that causes of overproduction of purine should be
considered

Answer 17

> 800 mg of uric acid per 24 h

Question 18

Cystic changes, well-defined erosions with sclerotic
margins (often with overhanging bony edges), and
soft tissue masses

Answer 18

advanced chronic tophaceous gout

Question 19

may aid earlier diagnosis by showing a
double contour sign overlying the articular cartilage

Answer 19

U/S

Question 20

can show specific features establishing the presence of urate crystals

Answer 20

Dual-energy computed tomography (CT)

Question 21

mainstay of treatment in acute attack of gouty arthritis

Answer 21

NSAID

Question 22

Tx of gout:

Answer 22

• Ice pack applications and rest
• Colchicine

Question 23

given as an intramuscular injection or orally for example, tapered with the resolution of the attack, can be effective in polyarticular gout

Answer 23

Glucocorticoids

Question 24

Tx for a single joint or a few involved joints,

Answer 24

• intraarticular triamcinolone acetonide, 20—40 mg,
• or methylprednisolone 25-50 mg

Question 25

Ultimate control of gout requires correction of the basic underlying defect:

Answer 25

hyperuricemia

Question 26

Attempts to normalize serum uric acid to ____ to prevent recurrent gouty attacks and eliminate tophaceous deposits are critical and entail a commitment to hypouricemic regimens and medications that generally are required for life

Answer 26

<300-360 umol/L (5.0-6.0 mg/dL)

Question 27

should be considered when hyperuricemia cannot be corrected by simple means

Answer 27

hypouricemic drug therapy

Question 28

decision to initiate hypouricemic therapy usually is made taking into consideration the :

Answer 28

- number of acute attacks (urate lowering may be cost-effective after two attacks) - serum uric acid levels (progression is more rapid in patients with serum uric acid >535 umol/L - patient’s willingness to commit to lifelong therapy - presence of uric acid stones

Question 29

can be used in px with good renal function who underexcrete uric acid, with <600mg in a 24-h urine sample

Answer 29

Uricosuric agents such as probenecid

Question 30

Urine volume should be maintained by ingestion of ___of water every day

Answer 30

1500 mL

Question 31

can be started at a dose of 250 mg twice daily and increased gradually as needed up to 3 g per day to achieve and maintain a serum uric acid level of <6mg/dL

Answer 31

Probenecid

Question 32

generally not effective in patients with serum creatinine levels >177 umol/L (2 mg/dL)

Answer 32

Probenecid

Question 33

Is another uricosuric drug that is more effective in patients with chronic kidney disease

Answer 33

Benzbromarone

Question 34

s a newer uricosuric; however, it is approved only in patients already on a xanthine oxidase inhibitor as an adjuvant at 200 mg per day

Answer 34

Lesinurad

Question 35

- most commonly used hypouricemic agent and is the best drug to lower serum urate in overproducers, urate stone formers, and patients with renal disease - The most serious side effects include: * life-threatening toxic epidermal necrolysis * systemic vasculitis * bone marrow suppression * granulomatous hepatitis * renal failure

Answer 35

Allopurinol

Question 36

40 or 80 mg once a day and does not require dose adjustment in mild to moderate renal disease

Answer 36

Febuxostat

Question 37

- pegylated uricase, available for patients who do not tolerate or fail full doses of other treatments * given intravenously usually at 8 mg every 2 weeks and can dramatically lower serum uric acid in up to 50% of such patients

Answer 37

Pegloticase

Question 38

Urate-lowering drugs are generally not initiated during ____, but after the patient is stable and low-dose colchicine has been initiated to decrease the risk of the flares that often, without anti-inflammatory treatment, occur with urate lowering

Answer 38

acute attacks

Question 39

Colchicine anti-inflammatory prophylaxis in doses of 0.6 mg one to two times daily should be given along with the hypouricemic therapy until the patient is normouricemic and without gouty attacks for

Answer 39

6 months or as long as tophi are present

Question 40

Should not be used in dialysis px and is given in lower doses to the px w/ renal disease or with P glycoprotein or CYP3A4 inhibitors such as clarithromycin that can incrase its toxicity

Answer 40

Colchicine