Let's Talk About George
You are treating a 45 year old man who now has had 4 gout attacks in the past year. He has no tophi, xrays show no joint destruction and his uric acid is 9. He also has type 2 diabetes, obesity, hypertension and some venous stasis changes in his legs. His current medications are: HCTZ, metformin, GLP-1.how do you counsel him on diet?
Decrease etoh, red meats, shellfish
What does this xray of the knee show? thank you orthobullets for the photo
chondrocalcinosis -- CPPD
CRP > 50 is associated with what 90% of the time?
BACTERIAL INFECTION
50% of first gout flares in men affect this joint
MTP (known as podagra)
Gold Standard for Gout and CPPD dx
Arthrocentesis/csystal analysis
You are treating a 45 year old man who now has had 4 gout attacks in the past year. He has no tophi, xrays show no joint destruction and his uric acid is 9. He also has type 2 diabetes, obesity, hypertension and some venous stasis changes in his legs. His current medications are: HCTZ, metformin, GLP-1. Does he qualify for treatment?
yes, acute and ULT
A 65 year old woman comes in with her first gout attack. What joint is most likely affected?
DIP
You patient presents in DIC and has a history of SLE. You get standard labs and see that their ESR is normal, CRP is elevated to 13, she has cytopenias, transaminitis and is appearing grossly ill. Why is her ESR normal?
60% of ESR is fibrinogen. In states of low fibrinogen, your ESR can be falsely low!!!!
Roughly how long does it take for your standard gout to resolve without treatment
10 days
- Can be days to a few weeks, in chronic disease flares can persist for months
rhomboid crystals are + or - birefringence in CPPD
+
You are treating a 45 year old man who now has had 4 gout attacks in the past year. He has no tophi, xrays show no joint destruction and his uric acid is 9. He also has type 2 diabetes, obesity, hypertension and some venous stasis changes in his legs. His current medications are: HCTZ, metformin, GLP-1. What would he need to have for his ULT goal to be 5?
tophi
What type of arthritis is on this xray finding of periarticular bony erosions, punched out bone lesions with disruption of the cortex (Described as overhanging edges)?
Monosodium uric acid deposition --- severe, long standing inadequately treated gout
What percentage of a health population will have a positive ANA at a 1:40-1:80 titer? How about 1:160?
~20-30%, 5%
when do flares typically begin (morning, midday, evening, nighttime) and after how long do they peak?
nightime, 12-24 hours
what color is negative birefringence
yellow
You are treating a 45 year old man who now has had 4 gout attacks in the past year. He has no tophi, xrays show no joint destruction and his uric acid is 9. He also has type 2 diabetes, obesity, hypertension and some venous stasis changes in his legs. His current medications are: HCTZ, metformin, GLP-1. What is his uric acid goal if you were to treat him?
6
what does this ultrasound show (Red arrow). It is of the tibial side of the knee
gout
My hands turn blue in the cold/often stay blue and cold but my pulses are strong and I don't have ulcers on my fingertips. Do I have raynauds?
No -- this is acrocyanosis.
Postmenopausal women have initial gout presentations that affect which two joints that are also typically affected by OA?
knees or fingers - usually OA will have affected them first
For more severe or long standing disease, polyarticular flares can occur with acute bursitis (largely olecranon and prepatellar mostly), periarthritis, and gouty panniculitis/cellulitis which can be seen as refractory bacterial soft-tissue infections
In men with established dz - flares can affect almost any joint, including the spine
positive birefringence is parallel or perpendicular
perpendicular
You are treating a 45 year old man who now has had 4 gout attacks in the past year. He has no tophi, xrays show no joint destruction and his uric acid is 9. He also has type 2 diabetes, obesity, hypertension and some venous stasis changes in his legs. His current medications are: HCTZ, metformin, GLP-1. How do you treat him?
1) see if you change change his HCTZ to losartan
2) is he a candidate for SGLT2i?
3) Acute treatment - i would opt for colchicine
4) He qualifies for ULT - allopurinol 100mg to start, then titrate up x 3 months, continuing colchicine ppx until 3 months s/p uric acid level at goal.
This subtype type of arthritis primarily affects DIP and PIP joints, leading to more joint erythema and swelling that other forms of primary hand arthritis of this type. it is more common in women, and radiographs have diagnostic findings of "seagull" or "gull wing" appearance in the finger joints
Erosive OA/CPPD with OA
-- controversial as to whether this is a separate disease entity or is party of a continuum of OA
How do you know which drug to choose to treat an acute gout flare? (Steroids, Colchicine, NSAIDs)
by the patient's comorbidities!
Colchicine - 1.2 mg at first symptoms of flare, followed by 0.6mg 1 hour late (most effective within 24 hours of start of flare). NOT IN CKD. Has GI side effects -- diarrhea
NSAIDs - high dose 5-7 days. NOT IN AC, relatively not with CHF
GCS - intra-articular, IM, or an oral burst x 5 days. CONSIDER T2DM, osteoporosis, infections
SEVERE or Refractory Gout w contraindications - Anakinra or Canakinumab
What is the gold standard for diagnosing a gout flare? Describe the finding.
negatively birefringent, needle like monosodium urate crystals, along w neutrophils in synovial fluid.
“Negatively birefringent” means that under polarized light, the crystals appear yellow when parallel to and blue when perpendicular to the polarizing axis of an optical filter.
What cell engulfs a monosodium urate crystal and triggers the inflammatory cascade, causing an acute gout attack?
macrophage