Gout And Pseudogout Treatment & Management

Content

• Differential Diagnosis
• Pain Management
• Joint Pain Vs Muscle Pain: Whats The Difference?
• Allopurinol
• High Flow Nasal Oxygen For Acute Respiratory Failure

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In patients with gout, modifiable risk factors such as obesity, diuretic use, high-purine diet, and alcohol intake should be addressed. A single dose of triamcinolone acetonide is effective in most patients. However, patients with longstanding or polyarticular attacks may require repeat doses. A regimen of 0.5 mg per kg of prednisone on day 1 and tapered by 5 mg each day is also very effective.

Differential Diagnosis

This is the average effective dosage necessary for patients with normal renal function. Frequently, allopurinol therapy is initiated at a dosage of 100 mg per day and increased in increments of 50 to 100 mg per day every two weeks until the patient's urate level is less than 6 mg per dL (355 μmol per L). Unless the serum urate level is lower than 6.4 mg per dL (380 μmol per L), the concentration at which urate saturates the extra-cellular fluid, crystals will not be absorbed, and tophi will continue to form. While it is clear that ultrasound can play an important role in the diagnosis and management of gout, limitations do exist in its applicability to daily use in the clinical environment. POCUS use is growing, especially with more affordable and portable machines, including hand-held devices, but training and quality improvement programs are needed to ensure quality care is being provided.

These potentially exacerbating factors should be identified and modified. Gout is a condition characterized by the deposition of monosodium urate crystals in the joints or soft tissue. The four phases of gout include asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. The peak incidence occurs in patients 30 to 50 years old, and the condition is much more common in men than in women. Patients with asymptomatic hyperuricemia do not require treatment, but efforts should be made to lower their urate levels by encouraging them to make changes in diet or lifestyle.

Pain Management

Findings of calcium pyrophosphate crystals and normal serum uric acid levels on joint fluid analysis can differentiate pseudogout from gout. Septic arthritis may present without a fever or elevated white blood cell count; arthrocentesis is required to distinguish this condition from acute gout. Septic arthritis can develop either from hematogenous seeding due to bacteria in the blood , direct inoculation of joint secondary to trauma or penetrating wounds , or contiguous spread of infection from bone into the joint cavity. The risk factors include intravenous drug use, prosthetic joints, indwelling catheters, chronic kidney disease, diabetes, malignancy, rheumatoid arthritis, and immunocompromised patients.

Joint Pain Vs Muscle Pain: Whats The Difference?

Patients with renal dysfunction or prior refractoriness to loop diuretics can be treated with higher doses of diuretics. Intravenous administration, concurrent use of 2 different diuretics, or the addition of an aldosterone antagonist can sometimes overcome diuretic resistance. Diuretics are the most effective pharmacologic means to provide symptomatic relief, but their effect on survival is unknown. Diuretics also provide rapid symptomatic relief of pulmonary and peripheral edema, due to their rapid onset of action. Loop diuretics are more effective for the treatment of symptomaitc fluid retention in cardiomyopathy than thiazide-type diuretics.

Acute gout sometimes resembles cellulitis and can lead to skin desquamation over the inflamed area. Gout can also cause acute bursitis or tenosynovitis of periarticular structures. Acute polyarticular gout is less common but has a more dramatic presentation. Acute gout can cause a high fever and leukocytosis (sometimes more than 40,000 white blood cells per mm3 [40 × 109 per L]) and may be difficult to distinguish from acute septic arthritis. If the diagnosis is unclear, bacteriologic cultures of the synovial fluid and blood are warranted, and corticosteroid injections should be deferred. Gout is caused by altered purine metabolism leading to hyperuricemia.

Diagnosis Of Recurrent Disease

Loop diuretics are effective in treating patients with heart failure due to their short half life and rapid onset of action. With the Family Medicine ITE right around the corner, we couldn’t be happier to oblige to this request. So without further adieu, here’s another pair of family medicine practice questions to help you in your ITE prep.

Deterrence And Patient Education

Dosing recommendations for colchicine in the treatment of acute gout have undergone modifications as awareness of its toxicities has increased. Newer recommendations trend toward lowered daily and cumulative doses. Limit NSAID use in elderly patients, because of the potential for adverse central nervous system effects. Use NSAIDs cautiously in patients with diabetes and those who are receiving concomitant angiotensin-converting enzyme inhibitors. Therapy with a combination of an oral urate-lowering agent, a xanthine oxidase inhibitor, and a uricosuric agent is appropriate when a patient's serum urate targets are not met by appropriate dosing with a xanthine oxidase inhibitor alone.

Allopurinol

Because magnesium and calcium resorption also occur in the same part of the nephron, loop diuretics also inhibit their resorption. This decreased resorption of osmotically active ions, results in increased urine production. A secondary effect of loop diuretics is to increase the production of prostaglandins, which results in afferent arteriolar vasodilation and an increase in renal blood flow. Not surprisingly, then, NSAIDs can reduce the efficacy of loop diuretics.

High Flow Nasal Oxygen For Acute Respiratory Failure

This can detect perirenal fluid, enlargement of the psoas muscle , and perirenal gas . - Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition. Migratory arthritis is characterized by pain and swelling in one or two joints. As the symptoms in that joint resolve, similar symptoms in another joint emerge, usually in an asymmetric location. So if your left shoulder is in pain and it subsides and the right shoulder becomes painful, you may have migratory arthritis. Migratory arthritis can affect people with other forms of arthritis or result from a serious illness.

If essential thrombocythemia is suspected, complete blood count , peripheral blood smear, iron studies, and genetic studies, including a quantitative JAK2 V617F assay, should be done, along with a BCR-ABL assay to exclude chronic myeloid leukemia . If the JAK2 and BCR-ABL assays are negative, CALR and MPL mutation assays should be done. The diagnosis of essential thrombocythemia is suggested by normal hematocrit, WBC count, mean corpuscular volume , and iron studies, as well as absence of the BCR-ABL translocation. Essential thrombocythemia is a diagnosis of exclusion and should be considered in patients in whom common reactive causes of thrombocytosis and other myeloproliferative neoplasms are excluded. If cytopenias are identified, myelodysplastic syndrome should be considered. Diuretics should be initiated at a low dose, which can be titrated until urine output increases and weight decreases.

As a general rule, asymptomatic hyperuricemia should not be treated, though ultrasonographic studies have demonstrated that urate crystal deposition into soft tissues occurs in a minority of patients with asymptomatic hyperuricemia. Patients with levels higher than 11 mg/dL who overexcrete uric acid are at risk for renal stones and renal impairment; therefore, renal function should be monitored in these individuals. The crystals can cause kidney stones, joint pain called arthritis, or deposits under the skin called tophi (TOE-feye). Using the clinical diagnostic rule, you determine that the patient has a score of 11.5 points.