Gout and pseudogout - unravelling the differences Scottish Heart ... · Gout and pseudogout –what...
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Transcript of Gout and pseudogout - unravelling the differences Scottish Heart ... · Gout and pseudogout –what...
Gout and pseudogout - unravelling the differences
Crystal arthropathies
What are they?
How to recognise them
Why is any of this of any relevance to a Heart Failure Specialist Nurse?
Unique role that Heart Failure Specialist Nurse can play.
Gout and pseudogout – what are they?
Forms of inflammatory arthritis caused by the precipitation of crystals into joint(s).
Urate crystals
Calcium pyrophosphate crystals
(Hydroxyapatite crystals)
Gout and pseudogout - similarities
Are caused by crystal deposition
Are more common in the elderly population.
Typically present with acute monoarthritis.
That is where the similarity between gout and pseudogoutends.
Gout
Gout
The most common form of inflammatory arthritis worldwide;
UK prevalence 2.5% in 2012 (increased from 1.4% in 1999).
Has humorous connotations
May not be taken seriously by
medical/nursing staff, relatives.
Gout – typical presentation
Gout – typical presentation
Severe pain in affected joint – usually 1st MTPJ (coolest joint) but can present elsewhere.
Unable to walk, sleep; “worst ever pain”
Affected joint swollen, tender, red, very painful on attempted active/passive movement (unlike cellulitis).
Similar appearance to septic arthritis.
May require admission to hospital, esp if first presentation.
Gout – typical presentation
Attack usually lasts 7-14 days
Joint(s) quiet between episodes, unless chronic tophaceous gout.
Gout – risk factors
Gout – risk factors
Alcohol Beer/lager > spirits > wine
Drugs Diuretics, ciclosporin, low dose aspirin
Family history of gout
Obesity
High purine diet
How to diagnose gout
Gout – diagnosis
Clinical presentation
Look for tophi
Exclude septic arthritis
Identification of urate crystals in synovial fluid aspirated from affected joint
The diagnosis is not based on serum urate.
Gout – management of acute attack
Non-pharmacolgical
Rest and cool affected joint (ice pack)
Pharmacological
Colchicine vs NSAID vs steroids (oral/IM/ intra-articular)
My preference is for colchicine 500 mcg bd
Stop if diarrhoea occurs
Gout – chronic management
Is prophylaxis needed?
Attacks > once/year
Risk factors ++
Modifiable risk factors achieved or unrealistic
Allopurinol vs febuxostat Both inhibit xanthine oxidase and reduce urate
production
Gout – chronic management
Allopurinol vs febuxostat
Both inhibit xanthine oxidase and reduce urateproduction.
The goal of therapy is a reduction in number of gouty episodes, and serum urate < 0.3 mmol/L.
Relatively straightforward to achieve, but often not achieved.
Pseudogout
Pseudogout
Resembles gout clinically – acute monoarthritis
Patient often admitted to hospital.
Typically wrist, knee in elderly patient after minor trauma.
Clinical assessment and investigations as for SA/gout
Acute management as for gout
Pseudogout – chronic management
Masterly inactivity
Low dose steroid (eminence based medicine)
Hydroxychloroquine – RCT evidence (Rothschild et al, 1997)
Crystal arthritis – what can a heart failure nurse do?
Crystal arthritis – what can a heart failure nurse do?
Pseudogout
Education of patient, carers
No indication for low purine diet
Crystal arthritis – what can a heart failure nurse do?
Gout
Gout – what can a Heart Failure nurse do?
Take it seriously.
Encourage appropriate use of urate-lowering therapy ie doctor shouldn’t just start ULT, but should modify dose to
achieve target serum urate.
Continue ULT during acute attack of gout.
Advise re alcohol.
Advise re diet.
Gout – what can a Heart Failure nurse do?
Dietary advice
Low purine diet
Cherries
High in anthocyanins – anti-oxidant and anti-inflammatory properties
High in vitamin C (uricosuric)
Gout – what can a Heart Failure nurse do?
Modify cardiac medication
Gout – what can a Heart Failure nurse do?
Can cardiac medication be altered to allow diuretic dose to be reduced?
Can cardiac medication incorporate those that may treat gout? - increase urate excretion (ie are uricosuric)
Examples of uricosuric drugs
Sulfinpyrazone
Benzbromarone
Losartan
Amlodipine
Atorvostatin
Fenofibrate
Summary
Hopefully you are now in a better to position to ...
Know what the crystal arthropathies are.
Advise patient Lifestyle
Continue urate-lowering therapy during an attack of gout
Simple local measures
Advise GP Don’t just start urate-lowering therapy, aim for serum urate
< 0.3 mmol/L.
And ...
Aware of your unique position in potentially modifying cardiac medication to reduce risk of further gouty attacks
Further information
The British Society for Rheumatology Guidelines for
the Management of Gout
doi:10.1093/rheumatology/kex156
Thank you
