Management of Gout:
A- Acute gouty arthritis:
- NSAIDs (fast-acting oral) e.g: naproxen, diclofenac, indomethacin for effective pain and swelling relief and should be taken as soon as symptoms are noticed till the clinical condition disappear.
- In patients with renal impairment or history of peptic ulcer, alternative treatment can be started which include oral colchicin. 1mg immediately then 0.5 mg 6 hourly until relief, but this may cause vomiting and severe diarrhea, to reduce this side effect we try other regimen, 0.5 mg 8 -12 hr although have slower effect.
- Synovial fluid aspiration: by itself gives a relief , and when combined with intra-articular corticosteroid (after exclusion of sepsis) can prevent re-accumulation of fluid.
B- Long term therapy:
- General measures: Diet and life style modification may reduce the frequency of acute attacks.
Wt. reduction, purine rich diet should be tempered or restricted, alcohol should be avoided. Dehydration and repetitive trauma, that may occur in certain exercises or occupation should be avoided. Medication known to contribute to hyperuricaemia should be substituted or eliminated if possible .
- Agents that reduce serum urate level: main indication for hypouricaemic agents are:
1- Recurrent attacks of acute gout.
2- Tophi formation.
3- Evidence joint or bone damage.
4- Associated renal disease.
5- Gout with greatly increase in serum uric acid.
Allopurinol (xanthine oxidase inhibitor) is usually the drug of choice , usually starting dose 100-300 mg/day, but lower dose 100 mg or less should be used in elderly or in patient with renal impairment.
Allopurinol should be avoided during acute attack ( because it may prolong or exacerbate the attack ) so it should be used when the attack is settled.
S.T. the initiating therapy with this agent may lead to sharp reduction in serum uric acid and can partially dissolve MSUM crystal and trigger acute attack. This can be minimized by starting lower dose of allopurinol or simultaneous administration of oral colchicin or NSAID in the first few weeks of therapy.
The aim of therapy is to bring s. uric acid to lower half of normal range , so s.uric acid monitoring is required initially every 3-4 weeks and the dose may increased by 100 mg increment till reach the acquired level (max. dose 900 mg/day) then yearly monitoring is advised.
Uricoseuric drugs: as probenecid or sulfinpyrozone.
It is equivalent to allopurinol to achieve required reduction in s.uric acid, but it is required several dose per day and require high urine flow to avoid uric acid crystallization in tubules.
Salicylic acid antagonize uricosuric drugs and should be avoided. Uricosuric drugs is contraindicated in:
1- over producer.
2- renal impairment.
3- urolethiasis.
It is a common age related disease usually above 55 years old. The crystal deposited in hyaline cartilage and fibro-cartilage of the joint (chondrocalcinosis), usually the knee joint is the target, the other common site are wrist and pubic symphysis.
CPPD deposition disease can be:
(1) in sporadic form "most common" in aged people, in apparent normal joint, mainly the knee.
(2) or associated with OA in addition to aging "common".
(3) or associated with metabolic disorders (rare). Of these metabolic diseases are haemochromatosis, hyperparathyroidism, hypophosphatasia, hypomagnesaemia and Wilson s disease.
(4) and rare form [familial], with an autosomal dominant inheritance, occur in earlier ages 3rd & 4th decades, polyarticular chondrocalcinosis.
Clinical presentation :
1- It is often clinically occult.
2- Acute synovitis (pseudogout): The attacks are similar to acute gout. It is he most common cause of acute monoarthritis in elderly. It mainly affects the knee joint. The other affected joints are {wrist, shoulder, ankle, elbow as monoarticular attacks}. Triggering factors include direct trauma and intercurrent illness or surgery.
Sepsis and gout are the main differential diagnosis, so sepsis should be excluded not because of similarity in presentation, but both sepsis and pseudogout can coexist.
3- Chronic pyrophosphate arthritis: Most patients are elderly, mainly women, the joints that are targeted are similar in distribution of pseudogout. Acute attacks may be superimposed on this chronic background. Affected joints show a feature of OA, with varying degree of synovitis.
Effusion and synovial thickening usually apparent at knee and wrists, with wrist involvement may lead to carpal tunnel syndrome.
Investigation:
• Synovial fluid examination is the principal diagnostic test:
a- For Identification of CPPD crystals.
b- To exclude sepsis by direct study and culture.
c- The aspirated fluid is often turbid and may be uniformly blood- stained, reflecting the severity of inflammation.
• Screening for metabolic or familial predisposition especially in those with "early onset, florid polyarticular, additional clinical features of predisposing disease".
• Radiographic features: may show chondrocalcinosis in cartilage, fibrocartilage occasionally capsule or ligament, with or without OA, chondrocalcinosis not always evident and its absence does not exclude the diagnosis. In the same way radiological appearance of chondrocalcinosis is often seen as an incidental findings in older subject.
Management:
? Acute pseudogout: aspiration of synovial fluid, quickly reduce the pain.
? In fluid reacumulation and florid acute pseudogout, intra-articular injection of steroid is usually required [after exclusion of sepsis].
? Oral NSAIDs and colchicine are also effective, as in gout, but should be avoided if possible in elderly.
? Treatment of underling metabolic disorder, if present, may reduce the recurrent of the attack .
? Early active mobilization is essential in elderly.
? In chronic pyrophosphate arthritis the mainline of management is same as for OA.
Basic Calcium phosphate (BCP) deposition:
The important musculoskeletal conditions associated with BCP are:-
Calcific periarthritis:
• Could be incidental deposition of crystals in supra-spinatus tendon.
• Or occasionally shedding of crystals into adjacent subacromial bursa and surrounding tissue provoke severe acute inflammation of bursa and surrounding tissue.
• Onset is abrupt, severe shoulder pain, area is swollen, hot, redness of overlying skin.
• The attack may triggered by trauma or could occur spontaneously. Men and women are affected equally "young adult and middle age".
• "periarticular tissue around greater trochanter, foot and hand are less commonly affected".
• Radiographs of the shoulder may show variable degree of calcification of supra-spinatus tendon.
• Aspiration of subacromial bursa, show thick white fluid , containing calcium-stained aggregates.
• The condition usually resolved within 1-3 weeks.
Treatment:
¤ Oral NSAIDs.
¤ Or by aspiration and local steroid injection (after exclusion of sepsis).
¤ In large deposits, which may cause painful impaingement syndrome may require surgical excision.
Osteoarthritis and BCP crystals deposition :-
® Although BCP crystal present commonly, alone or with CPPD, in synovial fluid of OA joint in moderate amounts.
® While large amounts of BCP crystals could be associated with distinct form of OA.
® Affects mainly large joints [shoulder, hip, knee], mainly the elderly and predominantly the women.
® The affected joint becomes markedly instable, sever pain, with rapid progression, joint is swollen with large effusion.
® Radiological changes show marked articular loss of cartilage and bone with minimal osteophyte (atrophic changes).
Treatment :
· Physical therapy.
· Oral analgesia.
· Sometimes local injection of steroid (after exclusion of sepsis).
· Most of the cases require joint replacement
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .