1. PA Days Presentation Brian K. Shrawder, PA-S LHU

2. 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.

3. Patient of the Day What’s in your differential? 1.Gout*** 2.Calcium Pyrophaosphate “Pseduo-gout” 3.Calcium Apatite 4.Septic Joint

4. Gout: Background “Disease of Kings” Found exclusively in Humans, Birds & Dalmatian canines Heterogeneous disease including: –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

5. Gout: Background Occurs with HYPERURICEMIA – elevations above 7 mg/dl (men) or 6 mg/dl (women). Deposits in superstaturations joints or kidneys

6. 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

7. 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

8. Gout: Clinical Features 4 stages : –Asymptomatic Hyperuricemia –Acute gouty arthritis –Intercritical gout –Chronic tophaceous

9. 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

10. 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 –1 st MCP site = #1 –‘works way up to foot’ –Explosive onset after falling asleep ‘well’ –Joint: Hot, red, dusky, swelling, extremely painful

11. 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

12. 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

13. Gout: Clinical Features 3. Intercritical Gout: –“interval gout” – periods between attacks –Some may never have 2 nd 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

14. 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

15. 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

16. 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

17. 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

18. 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.