Gout


Sign Normal GROUP 1 :
NON-Inflammatory
(Osteoarthritis, Hypothyroidism)
GROUP 2:
Inflammatory
(RA, Gout, CPPD, Spondylarthopathy)
GROUP 3:
Septic
Clarity Transparent Transparent Slightly opaque Opaque
Color Clear Yellow Yellow-opalescent Yellow-green
Viscosity High High Low Usually low
Culture (-) (-) (-) Often (+)
WBCs < 200 200-2000 2000-50,000 > 50,000
PMNs (%) < 25 < 25 > 50 > 75

A Chronic Disease of 4 Stages. Each Stage Needs Treatment

  1. Asymptomatic hyperuricemia
  2. Acute flares of crystallization
  3. Intervals between flares
  4. Advanced gout & complications

Clinical

Treatment

Conservative Measures to Lower Urate



Causes of Monoarticular Arthritis:

Condition Joint involved Unique features Tx
Septic Knee; unique sites in IVDU pt include sacroiliac, sternoclavicular & intervertebral joint S.aureus is most common ABx starting w/ Vancomycin
Gout First MTP, Knee Needle-shaped;
Negatively birefringent crystals;
Yellow when parallel & blue when perpendicular to polarizing light.
NSAID:
- Naproxen 500 mg po bid x10-14 days
- Ibuprofen 800 mg po q4-6h x10-14 days .
- Mobic 7.5-15 mg po qd x10-14 days.
When NSAID and COX-2 are contraindicated:
- Colchicine 1.2 mg po x1, then 0.6 mg po 1hr later x1. MAX: 1.8 mg total dose (Only use when NSAID and COX-2 are contraindicated)
Steroid :
- Prednisone 10 mg 4t qd x 5d,  2t qd x 5d,  1t qd x 5d, then stop #40
- Solumedrol 40mg intra-articular as single dose

DO NOT use allopurinol for acute gout.
Pseudogout
 
Knee, First MTP, Wrist Rhomboid-shaped;
Positively birefringent crystals;
Blue when parallel & yellow when perpendicular to polarizing light
NSAID:
- Naproxen 500 mg po bid x10-14 days
- Ibuprofen 800 mg po q4-6h x10-14 days .
- Mobic 7.5-15 mg po qd x10-14 days.
When NSAID and COX-2 are contraindicated:
- Colchicine 1.2 mg po x1, then 0.6 mg po 1hr later x1. MAX: 1.8 mg total dose (Only use when NSAID and COX-2 are contraindicated)
Steroid :
- Prednisone 10 mg 4t qd x 5d,  2t qd x 5d,  1t qd x 5d, then stop #40
- Solumedrol 40mg intra-articular as single dose
Osteoarthritis Hip, Knee Older age group, Weight-bearing joints Rest
NSAIDs
Joint replacement surgery
Trauma Knee Hemarthrosis associated with intra-articular fracture & ligamentous injury. Compression dressing & aspiration if necessary for symptomatic relief.

 
A monoarticular arthritis should be presumed to be septic until proven otherwise


Causes of Symmetic Polyarthritis:
Condition Joint involved Unique features Tx
Rhumatoid Hand (MCP & PIP joints), wrist Women in their 20s & 30s
Associsted with HLA-DR4 halotype.
RF
,
Anti-CCP ab

Early morning stiffness.
Sparing DIP joints.
Multisystemic involvement common.
NSAID:
- Naproxen 250-500 mg po bid. MAX: 1250mg/day
- Ibuprofen 400-800 mg po q4-6h prn. Max: 3200mg/day.
DMARD:
- Methotrexate 7.5-25 mg PO/IM once weekly on same day each wk. (PLUS folic acid)
- Sulfasalazine 0.5-1g/day PO for 7 days initially, increase by 500mg/day increments every week according to response. MAX: 2g/day given in 2-3 divided doses.
- Leflunomide 100mg po qd for 3 days initially, then 10-20 mg po qd
CORTICOSTEROIDS:
- Prednisone 1-10 mg po qd
- Methylprednosolone acetate 40-80mg intra-articularly q1-5 wks.
SLE All. Usually PIP & MCP joint of the hand Women 15-40 yr old; can be migratory; associated with rash: malar, discoid, or photosensitivity NSAID:
- Naproxen 250-500 mg po bid. MAX: 1250mg/day
- Ibuprofen 400-800 mg po q4-6h prn. Max: 3200mg/day.

Immunosuppressants
Rheumatic fever Larg joints (knees, ankles, elbows, wrist) Migratory NSAID:
- Naproxen 250-500 mg po bid. MAX: 1250mg/day
- Ibuprofen 400-800 mg po q4-6h prn. Max: 3200mg/day.

Immunosuppressants
Viral All joints