Crystal-Induced Arthritis. Rajesh Kataria, D.O. Southern Ohio Rheumatology
|
|
- Laurence Cook
- 5 years ago
- Views:
Transcription
1 Crystal-Induced Arthritis Rajesh Kataria, D.O. Southern Ohio Rheumatology
2 Disclosures Speaker: Rajesh Kataria, D.O. Relationships with commercial interests: Speakers Bureau - Horizon Presentation will include discussion of medication to treat gout and off label medication used to lower uric acid
3 Objectives 1. Identify goal uric acid level in chronic gout management & treatment options to achieve the goal 2. Be able to make dietary recommendations to gout patients 3. Be able to list syndromes caused by calcium pyrophosphate dihydrate crystals
4 Case Presentation JR is a 56 y/o WM admitted to SOMC with worsening fatigue, generalized weakness and ambulatory dysfunction Hospitalized 2 weeks earlier with diabetic foot ulcer and had undergone debridement Rheum consulted regarding R elbow and wrist pain
5 Case Presentation JR reports pain starting acutely 1 week prior w/o trauma. Had 1 similar episode years ago in the R elbow and was diagnosed with gout by PCP and has been on allopurinol daily Unable to move R wrist without severe pain
6 Case Presentation R wrist is warm, erythematous and extremely tender with palpation Temp 99.4 DDx?
7 Differential Diagnosis of Monoarticular Arthritis (Adults) Acute Infectious arthritis: Bacterial, viral Crystal arthritis: Gout, CPPD, BCP Traumatic arthritis Mechanical derangement Reactive arthritis: ARF Hemophilic arthritis Chronic Infectious arthritis: Mycobacterial, fungal, Lyme Crystal arthritis Tendinitis, bursitis Spondyloarthritis Ischemic necrosis Others
8 Case Presentation What tests/procedures should be undertaken?
9 Case Presentation ¼ cc of chalky white substance aspirated from R wrist Specimen sent to lab for what tests? Empiric Vancomycin, Decadron and colchicine started
10 Class III Synovial Fluid: Septic Arthritis Cloudy to Opaque, Low Viscosity >50,000 WBC/ l with neutrophil predominance
11 Normal Synovial Fluid Clear, Amber, High Viscosity <200 WBC/ l with mononuclear predominance
12 Case Presentation Gram stain Few wbcs Few gram + cocci Culture MRSA WBCs 16,000
13
14 Crystal Deposition Diseases Gout (monosodium urate crystal deposition) Characterized biochemically as extracellular urate supersaturation
15 Crystal Deposition Diseases Bone Cartilage CPPD crystals Synovium MSU crystals
16 Crystal-induced Inflammation Crystal Shedding Protein Coating Phagocytosis Release of Inflammatory mediators: PGE 2, O 2 radicals, Enzymes Local inflammation Release of Inflammatory mediators: IL-1, TNF-, others Systemic manifestations
17 ACR
18 Gout Screw up the vise as tightly as possible you have rheumatism; give it another turn, and that is gout. Anonymous
19 Acute Gouty Arthritis Described in 1683 by Thomas Sydenham Gouty patients are, generally, either old men or men who have so worn themselves out in youth as to have brought on a premature old age of such dissolute habits none being more common than the premature and excessive indulgence in venery and the like exhausting passions. The victim goes to bed and sleeps in good health. About two o clock in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle, or instep. The pain is like that of a dislocation and yet parts feel as if cold water were poured over them. Then follows chills and shivers and a little fever. The night is passed in torture, sleeplessness.
20 Acute Gouty Arthritis >90% of patients are males over 30 years of age Usually presents as an acute monoarthritis 50% of initial attacks occur in the 1 st MTP Podagra Almost always involves peripheral joints Acute onset with maximum pain in several hours Joint swelling, erythema, tenderness, pain on ROM Systemic symptoms of fever and chills may be present
21 Gout: A Progressive Condition Gout is the most common form of inflammatory arthritis, estimated to affect 8.3 million (3.9%) Americans. Adapted from Edwards NL. Gout. A. Clinical features. In: Klippel JH, Stone JH, Crofford LJ, White PH, eds. Primer on the Rheumatic Diseases. 13th ed. New York: Springer; 2008: Edwards NL, Crystal-Induced Joint Disease in ACPMedicine Textbook, Zhu Y, etal. Arth. & Rheumatism. 2011;63(10):
22 American College of Rheumatology (ACR) Preliminary Criteria for Gout Diagnosis Presence of MSU crystals in the joint fluid, or Tophus proved to contain MSU crystals by chemical or polarized light microscopy, or The presence of 6 of the following 12 clinical, laboratory, and radiographic criteria:
23 American College of Rheumatology (ACR) Preliminary Criteria for Gout Diagnosis - > 1 attack of acute arthritis - Maximal inflammation developed within 1 day - Attack of monoarticular arthritis - Joint redness observed - First MTP joint painful or swollen - Unilateral attack involving first MTP - Unilateral attack involving tarsal joint - Suspected tophus - Hyperuricemia - Asymmetric swelling within a joint on X-ray - Subcortical cysts without erosions on X-ray - Negative culture of joint fluid for microorganisms during attack of joint inflammation
24 Surgery Trauma Precipitation of Acute Gouty Arthritis Medical illness: MI, CHF, CVA Alcohol ingestion Medications: diuretics, cyclosporine Sudden change in urate concentration or solubility
25 Risk Factors & Co-Morbid Conditions Risk Factors Modifiable 1-6 Obesity Serum urate High-fructose corn syrup Purine-rich diets* o Meats (organ meats), Seafood Alcohol consumption Medications o Diuretics, Low-dose aspirin, Cyclosporine, Ethambutol Non-modifiable 7 Age Gender o Male o Postmenopausal females Co-Morbid Conditions Metabolic Syndrome 8 (63%) Hypertension Diabetes Mellitus Obesity Cardiovascular Disease Myocardial Infarction Peripheral artery disease Congestive heart failure Impaired Renal Function Bieber JD, Terkeltaub RA. Arthritis & Rheumatism. 2004;50(8): Choi HK et al. Arch Intern Med. 2005;165: Choi HK et al. Lancet 2004:363: Choi HK et al. NEJM 2004;350: Choi HK et al. Ann Intern Med. 2005;143: Choi et al. BMJ. 2008;336(7639): Wallace KL et al. J Rheumatol. 2004;31: Choi et al. Arthritis Rheum. 2007;57: Keenan RT, et al. Am. J. Med. 2010;124: Becker MA, et al. New Engl. J. Med. 2005;353(23): Emmerson BT. NEJM. 1996;334:445-51
26 Common Sites of Acute Gout Attacks Elbow Olecranon Bursa Wrist Fingers Knee Ankle Midfoot First Metatarsophalangeal (MTP) joint (eventually affected in ~ 90% of individuals with gout) Edwards NL. In: Goldman A, Schafer AI. Goldman s Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011.
27
28 Chronic Tophaceous Gout Occurs with longstanding untreated gout and results in tophi Collections of solid urate in connective tissue Typically not painful Can cause bone erosions
29 Harcourt
30 ACR
31 Class II Synovial Fluid: Crystal Arthritis Cloudy, Yellow, Low Viscosity 2,000-75,000 WBC/ l with neutrophil predominance
32 ACR
33 ACR Strongly negative birefringent crystals appear bright yellow when parallel with the axis of the compensator using polarizing light microscopy.
34
35 Harcourt
36 Treatment of Gout Acute gouty arthritis NSAIDs Intra-articular or systemic corticosteroids P.O. colchicine (1.2 mg followed by 0.6 mg 1 hour later, then 0.6 mg qd-bid for 7-10 days) I.M. ACTH Prophylaxis Low dose colchicine Low dose NSAIDs/corticosteroids
37 Treatment of Gout Control of hyperuricemia Xanthine oxidase inhibitors: allopurinol, febuxostat Uricosuric agents: probenecid, lesinurad, (losartan, fenofibrate*) Combination therapy: lesinurad/allopurinol Uricase (urate-oxidase): pegloticase
38 Indications for Urate Lowering Therapy Frequent attacks Tophaceous deposits Recurrent nephrolithiasis Urate nephropathy
39 Urate-Lowering therapies (ULTs) target different stages of purine metabolism Purines Humans Almost All Other Mammals Hypoxanthine xanthine oxidase X allopurinol febuxostat Xanthine xanthine oxidase X allopurinol C febuxostat Urate pegloticase uricase* H 2 O + O 2 H 2 O 2 Allantoin *Uricase is present in all mammals except man and higher apes. probenecid lesinurad Urinary Excretion Urinary Excretion Edwards NL. In: Goldman A, Schafer AI. Goldman s Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011.
40 ACR Guidelines for the Management of Gout At minimum, SUA < 6 mg/dl SUA<5 mg/dl for those with tophi and/or CTGA* Durable improvement in signs and symptoms of gout Reduced frequency of flares Clearance of tophi * CTGA: Chronic Tophaceous Gouty Arthropathy Khanna D, Fitzgerald JD, Khanna PP et al. Arthritis Care & Research. 2012;64(10): Single Agent Xanthine Oxidase Inhibitor (XOI) titrated to maximum appropriate dose (Alternative if XOI contraindicated or not tolerated: Probenecid) Serum urate target not achieved, continuing disease activity Add Uricosuric to XOI with both agents titrated to maximum appropriate dose Pegloticase Serum urate target not achieved, continuing disease activity
41 Treatment of Gout Maintaining serum uric acid < 6 mg/dl is associated with reduced risk of future gout attacks In a clinical study of 267 patients, 86% of patients who achieved a serum uric acid of < 6 mg/dl had no gout attacks during the observation period (> 1 year).
42 Treatment of Gout ACR guidelines recommend monitoring serum uric acid level every 2-5 weeks during uratelowering therapy titration, then every 6 months once serum uric acid target has been achieved
43 Treatment of Gout When is the best time to measure serum uric acid? At least 2 weeks post-flare, as serum uric acid levels may be artificially low up to 50% of the time during a flare
44 Treatment of Gout Lifestyle modifications Weight loss Limiting consumption of purine-rich meat (liver, kidney), seafood (shellfish, sardines, anchovies), and vegetables and legumes (asparagus, cauliflower, spinach, beans, peas, and mushrooms) Reducing alcohol intake, particularly beer Limiting high-fructose corn syrup intake Consuming dairy products Dietary restrictions may reduce urate levels by about 1 mg/dl
45 Calcium pyrophosphate deposition disease (CPDD) Due to articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals Chondrocalcinosis radiographic calcification of articular fibro- or hyaline cartilage An umbrella term that includes Acute CPP arthritis (pseudogout) OA with CPPD (pseudo-oa) Chronic CPP inflammatory arthritis Pseudo-RA Pseudo-neuropathic
46 Acute Pseudogout Part of the spectrum of calcium pyrophosphate deposition disease (CPDD) Due to articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals Generally occurs in patients over 50 years of age Slight female predominance Usually presents as an acute monoarthritis >50% of initial attacks occur in the knee Pseudogout is otherwise clinically similar to acute gouty arthritis though generally less intense
47 Precipitation of Pseudogout Surgery Trauma Medical illness: MI, CHF, CVA Transient decreases in Ca ++ Alteration of equilibrium between CaPP i in joint tissue and solution Increased solubility of CaPP i Crystal shedding
48 Conditions Associated with CPPD Disease True associations: Hyperparathyroidism, hemochromatosis, hypophosphatasia, hypomagnesemia, aging Probable associations: Hyperthyroidism, renal stones, ankylosing hyperostosis, ochronosis, Wilson s disease, hemophilic arthropathy Possible associations: Diabetes mellitus, hypertension, renal insufficiency, hyperuricemia, gynecomastia, IBD, RA, Paget s disease, acromegaly
49 Weakly positive birefringent crystals appear blue when parallel with the axis of the compensator using polarizing light microscopy. ACR
50
51
52 Basic Calcium Phosphate Deposition (BCP, Hydroxyapetite) Calcific tendinitis and bursitis Calcific periarthritis Primary Secondary: ESRD, Scleroderma Familial Intra-articular Most commonly involves shoulders and knees Acute arthritis Chronic erosive arthritis: Milwaukee shoulder
53 Approach to Acute Monoarticular Arthritis Synovial fluid analysis for crystals, gram stain and culture is essential If no crystals are found, generally treat as if septic arthritis even if gram stain is negative If crystals are found, it does not exclude concomitant septic arthritis Therapeutic trial of oral colchicine supports a diagnosis of acute gouty arthritis
54 Case Presentation 3 days later (Monday) Crystal search + MSU Final Diagnosis: Acute gouty + septic arthritis
1. To review the diagnosis of gout and its differential. 2. To understand the four stages of gout
Objectives 1. To review the diagnosis of gout and its differential GOUT 2. To understand the four stages of gout 3. To develop an approach for the acute treatment of gout Anthony Lim 9/13/12 Cycle 3 4.
More informationCrystal induced arthropathies. Dr. Amitesh Aggarwal
Crystal induced arthropathies Dr. Amitesh Aggarwal 1 Crystal induced Arthropathies Gout Pseudogout Debilitating illnesses; Recurrent episodes of pain and joint inflammation; Formation and deposition of
More informationGout A rapid review. Jeremy Jones
Gout A rapid review Jeremy Jones The Hyperuricemia Cascade Dietary purines Tissue nucleic acids Urate Endogenous purine synthesis Overproduction Hyperuricemia Underexcretion Silent tissue deposition Gout
More informationRheumatoid arthritis, seronegative spondylarthritides and gout. György Nagy
Rheumatoid arthritis, seronegative spondylarthritides and gout György Nagy Dec 4, 2017 Rheumatoid arthritis Rheumatoid arthritis Chronic, progressive, autoimmune disorder of the joints with extra-articular
More informationA Patient s Guide to Gout. Foot and Ankle Center of Massachusetts, P.C.
A Patient s Guide to Gout Welcome to Foot and Ankle Center of Massachusetts, where we believe in accelerating your learning curve with educational materials that are clearly written and professionally
More informationAcute hot swollen joint. Dr Edward Roddy Senior Lecturer in Rheumatology and Consultant Rheumatologist
Acute hot swollen joint Dr Edward Roddy Senior Lecturer in Rheumatology and Consultant Rheumatologist Acute monoarthritis: differential diagnosis Septic arthritis Crystal arthritis (gout, pseudogout) Haemarthrosis
More informationGOUT. Dr Krishnan Baburaj West herts NHS Trust
GOUT Dr Krishnan Baburaj West herts NHS Trust podagra Gout A disease of kings, the king of diseases History Louis XIV Emperor Augustus Henry VIII Introduction Gout an inflammatory arthritic condition that
More informationFor more information about how to cite these materials visit
Author(s): Seetha Monrad, M.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Noncommercial Share Alike 3.0 License: http://creativecommons.org/licenses/by-nc-sa/3.0/
More informationCase presentation. serum uric acid = 11.5 mg/dl 24-hour uric acid excretion = 300 mg
GOUT 55 y/o male 12 hours pain in my big toe & ankle went to bed last night feeling fine felt as if had broken toe this morning similar problems in right ankle & left wrist Case presentation lab studies
More informationEnhanced Primary Care Pathway: Gout
Enhanced Primary Care Pathway: Gout 1. Focused summary of gout relevant to primary care Significance: Gout is a chronic, progressive, inflammatory disease requiring appropriate long-term management. Gout
More informationUpdate on Gout for GPs
Update on Gout for GPs Dr Patrick Kiely PhD FRCP Consultant Physician and Rheumatologist St George s, London 2/3 1/3 Gut bacteria have uricase Chronic erosive arthropathy Clinical spectrum Making the diagnosis
More informationMono-articular Joint Complaints
Mono-articular Joint Complaints Derrick J. Todd, M.D., Ph.D. Associate Physician Department of Rheumatology, Immunology, and Allergy Brigham and Women s Hospital Instructor of Medicine Harvard Medical
More informationPodcast (Video Recorded Lecture Series): Gout for the USMLE Step One Exam. Howard J. Sachs, MD
Podcast (Video Recorded Lecture Series): Gout for the USMLE Step One Exam Howard J. Sachs, MD www.12daysinmarch.com Email: Howard@12daysinmarch.com Podcast (Video Recorded Lecture Series): Gout for the
More informationGout. Clinical features Most commonly affects middle-aged males. It is an acute and usually relapsing selflimiting
Gout Gout is a syndrome caused by an inflammatory response to the formation of monosodium urate monohydrate crystals which develop secondary to hyperuricemia. Acute and chronic forms are recognized. Hyperuricemia
More informationGout -revisited. Shrenik Shah
Gout -revisited Shrenik Shah definition Monosodium urate (MSU) crystal deposition episodic and later persistent joint inflammation and tophi All MSU crystal deposition- broader definition EULAR- European
More informationCOPYRIGHT. Update in Internal Medicine December 4, 2016
Update in Internal Medicine December 4, 2016 Fadi Badlissi, MD, MSc Director of the Musculoskeletal Medicine Unit The Orthopedic Department & Rheumatology Division Beth Israel Deaconess Medical Center
More informationGout 2.0. Scott Vogelgesang, M.D. Division of Immunology: Rheumatology & Allergy
Gout 2.0 Scott Vogelgesang, M.D. Division of Immunology: Rheumatology & Allergy Case 48 year old man presents with swollen, painful left toe that started overnight. Didn t hurt when he went to bed. No
More informationGOUT IN THE ELDERLY. Learning Objectives. Disclosure. Geriatric Grand Rounds. Geriatric Grand Rounds
Visit web sites: Tuesday, June 2, 2009 12:00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event
More informationOBJECTIVES GOUT GOUTY INFLAMMATION 6/10/2016 GOUT INCIDENCE AND PREVALENCE MONOSODIUM URATE CRYSTAL DEPOSITION DISEASE
GOUT Lisa Talbert, MD Family Medicine Update June 15, 2016 OBJECTIVES To be familiar with the clinical presentation and pathophysiology of gouty arthritis Be able to incorporate current guidelines when
More informationGOUT & PSEUDOGOUT OPSC 2018 HOWARD L. FEINBERG, D.O., F.A.C.O.I.., F.A.C.R.
GOUT & PSEUDOGOUT OPSC 2018 HOWARD L. FEINBERG, D.O., F.A.C.O.I.., F.A.C.R. Everything in excess is opposed by nature Eunuchs do not take the gout, nor become bald. GOUT Hyperuricemia is not gout Gout
More informationGout Hanan Abdel Rehim
Review article 35 Gout Hanan Abdel Rehim Department of Internal Medicine, Kasr-Al Aini School of Medicine, Cairo University, Cairo, Egypt Correspondence to Hanan Abdel Rehim, MD, 11 Ismaiel Wahby Street,
More informationGout- Treatment Updates. Harinder Singh, MD Rheumatology Mercy Internal Medicine Clinic Mason City, IA
Gout- Treatment Updates Harinder Singh, MD Rheumatology Mercy Internal Medicine Clinic Mason City, IA Gout Outline of purine metabolism: (1) amidophosphoribosyltransferase (2) hypoxanthine-guanine phosphoribosyltransferase
More informationAchieving Gout Goals in Your Practice An Interview with Paul P. Doghramji, MD, FAAFP
Achieving Gout Goals in Your Practice An Interview with Paul P. Doghramji, MD, FAAFP Dr. Paul Doghramji is attending physician at the Pottstown Memorial Medical Center and medical director of Health Services
More informationPennsylvania Academy of Family Physicians Foundation & UPMC 43rd Refresher Course in Family Medicine CME Conference March 10-13, 2016
Pennsylvania Academy of Family Physicians Foundation & UPMC 43rd Refresher Course in Family Medicine CME Conference March 10-13, 2016 Disclosures: Gout and Pseudogout Wayne Blount MD Speaker has no disclosures
More informationRheumatology Cases for the Internist
Rheumatology Cases for the Internist Marc C. Hochberg, MD, MPH Professor of Medicine Head, Division of Rheumatology and Clinical Immunology Vice Chair, Department of Medicine University of Maryland School
More information3/2/2014. Got Gout? Get a Plumber. Objectives. Disclosures
Got Gout? Get a Plumber. Heidi Garcia, PA-C Department of Rheumatology Division of Internal Medicine Mayo Clinic Arizona 2013 MFMER slide-1 Objectives Recall some of the history of Gout. Describe the pathophysiology
More informationGout Treatment Guidelines
Gout Treatment Guidelines Gout is a disorder that manifests as a spectrum of clinical and pathologic features built on a foundation of an excess body burden of uric acid, manifested in part by hyperuricemia,
More informationGout: Let s Be Crystal Clear. Dr. Philip A. Baer Seacourses Asia CME December 2017
Gout: Let s Be Crystal Clear Dr. Philip A. Baer Seacourses Asia CME December 2017 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or
More informationCHAPTER:2 GOUT. BY Mrs. K.SHAILAJA., M. PHARM., LECTURER DEPT OF PHARMACY PRACTICE, SRM COLLEGE OF PHARMACY
CHAPTER:2 GOUT BY Mrs. K.SHAILAJA., M. PHARM., LECTURER DEPT OF PHARMACY PRACTICE, SRM COLLEGE OF PHARMACY DEFINITION Gout is defined as a peripheral arthritis, resulting from the deposition of MSU crystals
More informationIndex. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A ABCG2 gene, in gout, 283 285 Acetaminophen, for CPP crystal deposition, 347 ACTH (corticotropin), for gout, 335 336, 383 ADAMTS proteins,
More informationGout: Develop treatment plan in William Jones, MS, RPh
Gout: Develop treatment plan in 2013 William Jones, MS, RPh (wnjones49@cox.net) Objectives Describe acute gouty arthritis Tx Describe Tx of chronic gouty arthritis. Define the target serum uric acid concentration
More informationGout. Crystal deposition disease: Imaging perspectives. Crystal associated arthropathies. Clinical Stages of Gout 07/06/60
Crystal associated arthropathies Crystal deposition disease: Imaging perspectives Warapat Virayavanich, MD Ramathibodi hospital, Mahidol University Commonly seen arthropathy MSU (gout) CPPD HADD Uncommon
More information395: Gout and Other Crystal-Associated Arthropathies
Harrison's Principles of Internal Medicine, 19e > 395: Gout and Other Crystal-Associated Arthropathies H. Ralph Schumacher; Lan X. Chen INTRODUCTION The use of polarizing light microscopy during synovial
More informationGout basics. Update on Gout. Production of uric acid. Gout basics. Crystal induced inflammation. Gout calculator. The important role of ultrasound
Update on Gout The important role of ultrasound Cheung C Yue, M.D. Gout basics Hyperuricemia gout Over 5 years, 22% >9 mg/dl develop gout Man 3-4 times more than women Risks: thiazide, cyclosporin, low
More informationPRELIMINARY CRITERIA FOR THE CLASSIFICATION OF THE ACUTE ARTHRITIS OF PRIMARY GOUT
895 PRELIMINARY CRITERIA FOR THE CLASSIFICATION OF THE ACUTE ARTHRITIS OF PRIMARY GOUT STANLEY L. WALLACE, HARRY ROBINSON, ALFONSE T. MASI, JOHN L. DECKER, DANIEL J. McCARTY. and T SAI-FAN Yo The American
More informationGout. Edward Roddy, 1 Christian D Mallen, 1 Michael Doherty 2 CLINICAL REVIEW
Gout Edward Roddy, 1 Christian D Mallen, 1 Michael Doherty 2 1 Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele ST5 5BG, UK 2 Academic Rheumatology, University
More informationLecture 8 Gout Hinch. Pathogenesis of acute attacks
Gout: disease characterized by deposition of monosodium crystals in soft tissues (cartilage, tendons, bursa) recurrent episodes of acute joint pain & inflammation Pathogenesis of acute attacks Epidemiology:
More informationDiagnosis and Management of Gout in 2011
October 18, 2011 Early and accurate gout diagnosis and disease management are essential. Making the clinical diagnosis takes into consideration the differential diagnosis supported by the use of clinical,
More informationCrystal arthritis: contemporary approaches to diseases of antiquity
Crystal arthritis: contemporary approaches to diseases of antiquity Mark Lillicrap MRCP PhD PGCMedEd, Consultant Rheumatologist, Hinchingbrooke Hospital, Huntingdon; Associate Clinical Dean, University
More informationSubject: Krystexxa (pegloticase) Original Effective Date: 06/26/13. Policy Number: MCP-138. Revision Date(s):
Subject: Krystexxa (pegloticase) Original Effective Date: 06/26/13 Policy Number: MCP-138 Revision Date(s): Review Date(s): 12/16/15; 6/15/2016; 3/21/2017 DISCLAIMER This Molina Clinical Policy (MCP) is
More informationBODY FLUID ANALYSIS. Synovial Fluid. Synovial Fluid Classification. CLS 426 Urinalysis and Body Fluid Analysis Body Fluid Lecture Session 1
BODY FLUID ANALYSIS Synovial Fluid Serous fluids the 3 P s Peritoneal Pleural Pericardial Cerebrospinal Fluid Karen Keller, MT(ASCP), SH Synovial Fluid Lubricant and sole nutrient source of joint. Normal
More informationUpdate on the Management of Gout
Update on the Management of Gout Professor Anthony D Woolf Duke of Cornwall Department of Rheumatology Royal Cornwall Hospital, Truro, UK Peninsular Medical School Universities of Exeter and Plymouth People
More informationRheumatology Review Update in Internal Medicine COPYRIGHT. Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center.
Rheumatology Review Update in Internal Medicine Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center Boston MA Case #1 True statement(s) regarding etanercept and leflunomide, for the treatment
More informationAn update on the management of gout
An update on the management of gout 8 The management of gout involves treatment of an acute attack, lifestyle modification and urate lowering treatment to achieve a target serum urate level. Recent evidence
More information2.0. Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved. 24 The Nurse Practitioner Vol. 40, No. 8
2.0 CONTACT HOURS 24 The Nurse Practitioner Vol. 40, No. 8 www.tnpj.com Treatment and gout prevention of o leva Abstract: Gout is a disorder of purine metabolism that primarily occurs in adult males. Elevated
More informationEvidence Based Medicine and the Treatment of Gout
Evidence Based Medicine and the Treatment of Gout DANIEL P. EVANS, DPM, FACFAOM Professor, Department of Podiatric Medicine and Radiology Dr. Wm. Scholl College of Podiatric Medicine GORDON K. LAM, MD,
More informationClinical Practice Guideline. Gout. Version
Clinical Practice Guideline Gout Version 1.1.2017 August 2017 Table of Contents Introduction...5 Stages of Gout...7 Asymptomatic Hyperuricemia... 7 Acute Intermittent Gout... 7 Advanced Gout... 8 Diagnosis...8
More informationPART MUSCULOSKELETAL DISORDERS
PART 12 MUSCULOSKELETAL DISORDERS CASE STUDY 77 GOUT For the Patient Case for this case study, see the printed book. DISEASE SUMMARY Definitions Gout is a syndrome of abnormal purine (i.e., DNA nucleotide
More informationSpondyloarthritis: A Gouty Display
Spondyloarthritis: A Gouty Display Preetam Gongidi 1*, Shawn Gough-Fibkins 2 1. Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, USA 2. Broward General Medical Center,
More informationUloric Step Therapy Program
Uloric Step Therapy Program Policy Number: 5.01.584 Last Review: 7/2017 Origination: 7/2014 Next Review: 7/2018 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for brand
More informationHow to Summary Record. Anatomical Site Code. Anatomical Site Code. Chapter XIII M00-M99 Musculoskeletal System & Connective Tissue.
How to Summary Record What Where When Infection Region Congenital Inflammation Level Infant Degeneration Medial/Lateral Juvenile Chapter XIII M00-M99 Musculoskeletal System & Connective Tissue Traumatic
More informationMONOSODIUM URATE CRYSTALS IN THE KNEE JOINTS OF PATIENTS WITH ASYMPTOMATIC NONTOPHACEOUS GOUT
148 MONOSODIUM URATE CRYSTALS IN THE KNEE JOINTS OF PATIENTS WITH ASYMPTOMATIC NONTOPHACEOUS GOUT JOHN S. BOMALASKI, GERONIMO LLUBERAS, and H. RALPH SCHUMACHER, JR. We aspirated synovial fluid from the
More informationDrugs Used to Treat Gout. Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia
Drugs Used to Treat Gout Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia Gout is a metabolic disease characterized by recurrent episodes of acute arthritis
More informationLong-term Treatment of Gout: New Opportunities for Improved Outcomes
Long-term Treatment of Gout: New Opportunities for Improved Outcomes Paul P. Doghramji, MD, FAAFP CONTINUING MEDICAL EDUCATION LEARNING OBJECTIVES Make a presumptive diagnosis of gout based on history
More informationGout: Update in therapeutics
Summary Gout: Update in therapeutics 29/11/14 Caroline van Durme CHU de Liège Maastricht University Medical Centre+ Why treating gout? Guidelines: ACR 12 Drugs: Colchicine Allopurinol: what about the kidney?
More informationNew Drug Evaluation: lesinurad tablet, oral
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationKrystexxa (pegloticase) Document Number: IC-0158
Krystexxa (pegloticase) Document Number: IC-0158 Last Review Date: 06/27/2017 Date of Origin: 02/07/20103 Dates Reviewed: 11/2013, 08/2014, 07/2015, 07/2016, 09/2016, 12/2016, 03/2017, 06/2017 I. Length
More informationGout and Hyperuricemia
Gout and Hyperuricemia 100 Access publication Sep. 2016 Computed tomography manifestation of gouty arthritis Hu Yabin 1, Yang Qing 1, Cao Qiang 2, Ren Jianan 1, Yang Qing * Objective: Of the most commonly
More informationManaging Gout A Review of the Research for Adults
Managing Gout A Review of the Research for Adults e Is This Information Right for Me? This information is right for you if: Your health care professional* has said that you have gout. You are age 18 or
More informationRHEUMATOLOGY OVERVIEW. Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center
RHEUMATOLOGY OVERVIEW Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center What is Rheumatology? Medical science devoted to the rheumatic diseases
More informationCopyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
14 The Nurse Practitioner Vol. 41, No. 14 www.tnpj.com 2.5 CONTACT HOURS 2.5 CONTACT HOURS Gout An update on for primary care providers Abstract: This article discusses the current beliefs regarding the
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Krystexxa) Reference Number: CP.PHAR.115 Effective Date: 06.01.13 Last Review Date: 02.19 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder
More informationGouty arthritis: an approach for general practice
Gouty arthritis: an approach for general practice Abstract Tikly M, MBBCh, PhD, FCP(SA), FRCP, Professor of Rheumatology Makan K, MBChB, FCP(SA), Rheumatology Fellow Division of Rheumatology, Chris Hani
More informationLesinurad in Combination With a Xanthine Oxidase Inhibitor for Treatment of Hyperuricemia Associated With Gout
Lesinurad in Combination With a Xanthine Oxidase Inhibitor for Treatment of Hyperuricemia Associated With Gout Briefing Document for the Arthritis Advisory Committee Meeting Date: 23 October 215 Ardea
More informationCurrent treatment options for acute and chronic gout
DRUG REVIEW n Current treatment options for acute and chronic gout Kelsey Jordan FRCP and Andrew Jeffries PGDip, MRCP Gout is the only curable form of arthritis, yet only a third of patients with chronic
More informationTHE BURDEN OF SUBCLINICAL SYNOVITIS IN GOUT
THE BURDEN OF SUBCLINICAL SYNOVITIS IN GOUT PRIYA CHOWALLOOR, MBBS, FRACP This thesis is presented for the degree of Masters of Clinical Research of The University of Western Australia SCHOOL OF MEDICINE
More informationRheumatology Red Flags and Emergencies :Workshop DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC
Rheumatology Red Flags and Emergencies :Workshop DR. MICHAEL STARR DIVISION OF RHEUMATOLOGY MUHC Family Medicine Review Course, November 28th, 2018 Disclosures Amgen Janssen Roche BMS Pfizer UCB Novartis
More informationGout is a common systemic metabolic. Diagnosis of Gout: Clinical, Laboratory, and Radiologic Findings REPORTS. Naomi Schlesinger, MD
Diagnosis of Gout: Clinical, Laboratory, and Radiologic Findings Naomi Schlesinger, MD Abstract Acute gouty arthritis typically presents with a sudden and severe exquisitely painful joint, most classically
More informationA case of extensive synovial involvement by tophaceous gout
A case of extensive synovial involvement by tophaceous gout Nausheen Khan, MB BS, FCRad (D) Irma van de Werke, MB ChB, FRCR Farzanah Ismail, MB ChB, FCRad (D) Department of Radiology, Kalafong Hospital,
More informationMEDICAL POLICY PEGLOTICASE (KRYSTEXXA ) POLICY NUMBER MP POLICY TITLE. Original Issue Date (Created): January 1, 2011
Original Issue Date (Created): January 1, 2011 Most Recent Review Date (Revised): September 24, 2013 Effective Date: November 1, 2013 I. POLICY PREAUTHORIZATION REQUIRED Note: Requests for pegloticase
More informationChondrocalcinosis after parathyroidectomy*
Ann. rheum. Dis. (1976), 35, 521 Chondrocalcinosis after parathyroidectomy* J. S. GLASS AND R. GRAHAME From Guy's Arthritis Research Unit, Guy's Hospital Medical School, London SE] 9RT Glass, J. S., and
More informationTherapy for Gout: The Past
Advances in Therapy for Gout: 2011 The Past, Present, and Future Therapy for Gout: The Past May 22, 1997 Pity a Tyrannosaur? Sue Had Gout By MALCOLM W. BROWNE Jonathan Graf, M.D. Associate Professor of
More informationOsteoarthritis. Rheumatology Update. Gout 1/17/2013
Osteoarthritis Rheumatology Update Richard Zweig, MD January, 2013 Degeneration of cartilage over time accompanied by increase in bone density and bone formation around the joint Risks include: aging,
More informationUrate Lowering Efficacy of Febuxostat Versus Allopurinol in Hyperuricemic Patients with Gout
Philippine Journal of Internal Medicine Meta-Analysis Urate Lowering Efficacy of Febuxostat Versus Allopurinol in Hyperuricemic Patients with Gout Erika Bianca S. Villazor-Isidro, M.D.*; John Carlo G.
More informationCase Report Refractory Gout Attack
Case Reports in Medicine Volume 2012, Article ID 657694, 4 pages doi:10.1155/2012/657694 Case Report Refractory Gout Attack Simone Fargetti, Claudia Goldenstein-Schainberg, Andressa Silva Abreu, and Ricardo
More informationWhat will happen in the future? How will gout be diagnosed? How is gout treated? prevent
Rheumatology Day Unit Dr J Hamilton 0191 4458359 0191 4455240 (9-5 Mon-Fri) Dr C Heycock 0191 4452198 Answer phone on 24hours Dr C Kelly 0191 4452193 Dr V Saravanan 0191 4456055 Dr M Rynne 0191 4458359
More informationImplementing AHRQ Effective Health Care Reviews Helping Clinicians Make Better Treatment Choices
Implementing AHRQ Effective Health Care Reviews Helping Clinicians Make Better Treatment Choices Gout: Diagnosis and Management Practice Pointers by MATTHEW R. NOSS, DO, MSEd, U.S. Army Health Clinic,
More informationRheumatologic Emergencies It s not just swollen joints. Joanne Homik Rheumatologist University of Alberta
Rheumatologic Emergencies It s not just swollen joints Joanne Homik Rheumatologist University of Alberta Or is it? Disclosures No relevant conflicts of interest regarding the content of this presentation
More informationGout is a disease resulting from the deposition of monosodium urate crystals in. Diagnosis and Management of Gout. 1 of 7 09/04/22 12:11.
Advertisement Home Page > News & Publications > Journals > American Family Physician > Vol. 59/No. 7 (April 1, 1999) Remember Me Log-in Help Advanced Search Diagnosis and Management of Gout JOEL R. PITTMAN,
More informationWhat organ system is involved? What is the pathology? What is the possible etiology?
Johan van Rensburg What organ system is involved? What is the pathology? What is the possible etiology? Genetic Environmental What are the possible complications? How is the patient s functioning impaired?
More informationCost-effectiveness of lesinurad (Zurampic ) for the treatment of adult patients with gout
Cost-effectiveness of lesinurad (Zurampic ) for the treatment of adult patients with gout The NCPE has issued a recommendation regarding the cost-effectiveness of Lesinurad (Zurampic ) in combination with
More informationThe 2010 Competency Standards addressed by this activity include (but may not be limited to): 4.2.2, 4.2.3, 6.1.2, 6.2.1, 7.1.2, 7.1.3,
UPDATE ON GOUT Learning objectives: After completing this activity, pharmacists should be able to: 1. describe the mechanisms underlying hyperuricaemia 2. state the risk factors for development of gout
More informationGout Goals Are Not Being Achieved!! Strengthening The Provider/Patient Alliance Featuring PEPtools TM JointsAflame
Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance QS Priorities Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance Paul P. Doghramji, MD, FAAFP
More informationCase Report Pseudoseptic Arthritis: A Case Series and Review of the Literature
Case Reports in Infectious Diseases Volume 2011, Article ID 942023, 4 pages doi:10.1155/2011/942023 Case Report Pseudoseptic Arthritis: A Case Series and Review of the Literature Brian P. Oppermann, 1
More informationArthritis due to deposition diseases: differential diagnosis in conventional radiology
Arthritis due to deposition diseases: differential diagnosis in conventional radiology Poster No.: C-1599 Congress: ECR 2016 Type: Educational Exhibit Authors: A. P. Pissarra, R. R. Domingues Madaleno,
More informationNew Drugs for the Primary Care Provider: What You Need to Know
4:00 4:35 pm New Drugs for the Primary Care Provider: What You Need to Know SPEAKER Gerald W. Smetana, MD Presenter Disclosure Information The following relationships exist related to this presentation:
More informationEvaluation and Management of Monoarticular Arthritis
Evaluation and Management of Monoarticular Arthritis Robert W. Janson, MD FACR FACP Division of Rheumatology Denver VA Medical Center; UCSOM Learning Objectives Identify the causes of acute and chronic
More informationGout Goals Are Not Being Achieved!! Strengthening The Provider/Patient Alliance Featuring PEPtools JointsAflame
Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance QS Priorities Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance Featuring PEPtools TM JointsAflame
More informationGOUT GO FOR SIX WITH. Everything You Need to Know About Gout & Uric Acid PLUS:
GO FOR SIX WITH Everything You Need to Know About Gout & Uric Acid GOUT PLUS: How to gain control of symptoms A gout-friendly eating style Medication recommendations to discuss with your doctor Lifestyle
More informationLECTURE 5: DRUGS IN GOUT
Red : important Black : in male / female slides Pink : in female s slides only Blue : in male s slides only Green : Dr s notes Grey: Extra information, explanation Editing File LECTURE 5: DRUGS IN GOUT
More informationGout FACTSHEET REAL LIFE STORY
1 What is gout? Gout is a type of arthritis where swelling and severe pain develops rapidly in joints, especially at the base of the big toe. Gout affects approximately one in 30 adults, most commonly
More informationGout Goals Are Not Being Achieved!! Strengthening The Provider/Patient Alliance Featuring PEPtools JointsAflame
Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance QS Priorities Gout Goals Are ot Being Achieved!! Strengthening The Provider/Patient Alliance Featuring PEPtools TM JointsAflame
More informationAcute gout and the accident and emergency department
Archives of Emergency edicine, 1984, 2, 89-95 Acute gout and the accident and emergency department R. H. HARDY AND B. NATION Department of Accident and Emergency edicine, Hereford General Hospital, and
More informationRheumatology E-learning. University of Szeged Department of Rheumatology and Immunology
Rheumatology E-learning University of Szeged Department of Rheumatology and Immunology The definition of gout Arthritis urica: an acute inflammatory process elicited by the precipitation of uric acid cristals
More informationFor more information about how to cite these materials visit
Author(s): Mark McQuillan, M.D., F.A.C.P., F.H.M., 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Non-Commercial 3.0 License:
More informationRheumatology Updates for the Primary Care Provider
Rheumatology Updates for the Primary Care Provider Jean Tayar, MD, RhMSUS Associate Professor Section of Rheumatology and Clinical Immunology Department of General Internal Medicine UT MD Anderson Cancer
More informationWORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2464/03
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2464/03 BEFORE: T. Carroll: Vice-Chair G.V. Stewart: Member Representative of Employers D. Gillies: Member Representative of Workers HEARING:
More informationClass Update: Drugs for Gout
Copyright 2012 Oregon State University. ll Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationGOUT GO FOR SIX WITH. Everything You Need to Know about Gout & Uric Acid PLUS:
GO FOR SIX WITH Everything You Need to Know about Gout & Uric Acid GOUT PLUS: How to gain control of symptoms A gout-friendly eating style Medication recommendations to discuss with your doctor Lifestyle
More information