Transcript Berger
ACUTE MONOARTHRITIS BERGER’S B’S • BUGS • BLOOD • BIREFRIGENCE CALCIUM PYROPHOSPHATE (cppd) • • • • • Acute pseudogout Female predominant Knees/Shoulders/Wrists/MCP’s High fever and sed rate possible Can coexist in same joint with true infectious etiology: Unlike gout CALCIUM HYDROXYAPATITE • • • • • “Milwaukee Shoulder” Shoulders/knees/hips Hemarthrosis associated Rotator cuff destruction Fever and high sed rate less common than in CPPD 52 y.o. WM presents with 7 hrs. of pain in R great toe. No previous hx of similar problems. Healthy with no significant PMH. What else do you want to ask? MORE HISTORY • TRAUMA • FEVER • UROGENITAL SX • EYE PAIN OR REDNESS • HX OF NEPHROLITHIASIS • RASH • ETOH DIFFERENTIAL DX • GOUT • REITER’S (INCOMPLETE) • INFECTION • HEMARTHROSIS (TRAUMA) LABS ??? • CBC AND BUN/CREATININE – REMEMBER SECONDARY CAUSES OF GOUT: • LEUKEMIA/MYELOMA • AZOTEMIA • HIGH CELLULAR TURNOVER – PSORIASIS – TREATMENT OF PERNICIOUS ANEMIA • URIC ACID??? TREATMENT • NONSTEROIDALS – WHICH ONE CAN’T YOU USE? • COLCHICINE – NEVER IV • INJECTION WITH STEROIDS • ORAL STEROIDS TREATMENT • ALLOPURINOL • PROBENECID • FEBUXOSTAT NEVER, NEVER, NEVER IN SETTING OF ACUTE ATTACK. WAIT 6 WEEKS FOLLOW UP? • F/U in 6 weeks and begin allopurinol then • F/U in 10 weeks and begin allopurinol then • No F/U FOLLOW UP • If no evidence of chronic destructive disease or tophaceous gout, no F/U necessary • Consider prophylaxis only for recurrent attacks or destructive/tophaceous disease PROPHYLAXIS • 50 % OF ALL GOUT PATIENTS REQUIRE PROPHYLAXIS • 90 % ARE HYPOEXCRETORS • 10 % ARE OVERPRODUCERS • DOESN’T MATTER IF THEY HAVE PMH OF KIDNEY STONES PROBENECID • INCREASES URINARY EXCRETION OF URIC ACID • CONTRAIINDICATED IN NEPHROLITHIASIS • WON’T WORK WITH CREATININE ABOVE 2 • WON’T KILL ANYONE ALLOPURINOL • “ALLOPEALINOL”:TEN • KILLS PEOPLE • XANTHINE OXIDASE INHIBITOR • RENAL/HEPATIC DISEASE PUT PATIENTS AT RISK • ORPHAN DRUG? FEBUXOSTAT • NOVEL NONPURINE XANTHINE OXIDASE INHIBITOR • BETTER THAN ALLOPURINOL IN REDUCING URIC ACID AT 2 MONTHS • NO ADJUSTMENT NEEDED FOR RENAL DISEASE • DOSE 40MG TO BEGIN: 80MG IF NECESSARY PROPHYLAXIS • CHRONIC DESTRUCTIVE OR TOPHACEOUS DISEASE GET BOTH DRUGS • HX OF NEPHROLITHIASIS GETS ALLOPURINOL OR FEBUXOSTAT • USE 24 HOUR URINARY URIC ACID EXCRETION AS GUIDE • CAN USE SPOT URIC ACID CLEARANCE SPOT URIC ACID CLEARANCE MID-MORNING URINE URINE URIC ACID x SERUM CREATININE URINE CREATININE SHOULD = .4 .6 OR GREATER IS HYPEREXCRETOR/OVERPRODUCER DOSING • WAIT 6 WEEKS AFTER LAST ACUTE ATTACK • PROBENECID – START 500MG BID – TOP DOSE OF 1 GRAM BID • ALLOPURINOL – START 300MG QD WITH NORMAL RENAL FUNCTION – ADJUST DOSE FOR AZOTEMIA ROLE FOR COLCHICINE • HISTORICALLY USED FOR PROPHYLAXIS IN ADDITION TO OTHER AGENTS • .6MG BID • COLBENEMID: 1 BID – .6MG OF COLCHICINE – 500MG OF PROBENECID ADJUSTING DOSE • DRAW SERUM URIC ACID (FOR FIRST TIME!) WHEN PROPHYLAXIS BEGINS • MONITOR SERUM URIC ACID Q 6 MONTHS AND ADJUST DOSE UPWARDS TO ACHIEVE SERUM URIC ACID 5-7MG/DL. INTERCURRENT ATTACKS • USE NONSTEROIDAL OR INCREASE COLCHICINE DOSE • IF PATIENT HAS BEEN NONCOMPLIANT WITH PROPHYLAXIS REGIMEN AND HAS “RESTART FLARE”, STOP PROHYLAXIS FOR 6 WEEKS AND RESTART AFTER FLARE RESOLVES SOME PEARLS • ALLOPURINOL GIVEN WITH IMURAN CAUSES APLASIA, MONITOR CAREFULLY • CYCLOSPORINE CAUSES GOUT • “MOONSHINE” CAUSES TERRIFIC GOUT BECAUSE OF LEAD AND ETOH EFFECTS: “SATURNINE GOUT” MORE PEARLS • ARBS PRODUCE SAME EFFECT AS PROBENECID INCREASE RENAL EXCRETION OF URIC ACID • URICASES ARE ALSO IN PHARMA PIPELINE: RASBURICASE