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CRYSTAL ARTHRITIS

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Osteoarthritis with/out pseudogout. Chondrocalcinosis. Neuropathic joint ... Osteoarthritis (found in 70% of OA synovial fluid) BCP Long-Term Treatment ? ... – PowerPoint PPT presentation

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Title: CRYSTAL ARTHRITIS


1
CRYSTAL ARTHRITIS
  • Mark Jarek MD,FACP,FACR

2
CRYSTAL ARTHRITIS
  • GOUT (monosodium urate)
  • PSEUDOGOUT (calcium pyrophosphate)
  • HYDROXYAPATITE

3
GOUT
  • Inflammatory arthritis mediated by the
    crystallization of uric acid within joints, tophi
  • Often associated with hyperuricemia
  • Prevalence in US 2.7 (6 million)
  • Incidence 62.3 /100,000 (2-fold increase)
  • Associations DM, HTN, metabolic syndrome,
    obesity, CVD, renal stones, CPPD
  • Risk Factors genetics, age, CRF, serum uric
    acid, diet, alcohol, medications

4
MEDS- Increased Urate Pool
  • DIURETICS (RR 1.77, CI 1.4-2.2)
  • Low Dose salicylates
  • B-blockers
  • PZA, ethambutol
  • Cyclosporin, tacrolimus
  • Insulin

5
MEDS- Decreased Urate Pool
  • High dose Salicylate
  • Losartan
  • Fenofibrate
  • Amlodipine
  • Vitamin C
  • Probenecid, sulfinpyrazone, benzbromarone
  • Allopurinol, uricase, febuxostat

6
Hyperuricemia Preclinical Period
  • 6.8mg/dl based on urate supersaturation
  • 5-8 - most asymptomatic 20 get gout
  • Onset males age 30, females postmenopausal
  • Duration 10-15 yrs before gout
  • 80 due to undersecretion, 20 due to
    overproduction
  • Determined by 24 hr urine collection

7
GOUT
  • Urate precipitation leads to acute gouty
    arthritis
  • Local factors temperature, pH, trauma, joint
    hydration
  • Systemic factors hydration state, fevers, meds,
    alcohol, co-morbid conditions
  • Attack resolves spontaneously 10-15 days

8
GOUT
  • ACUTE GOUT
  • First attack 4th-6th decade for men
  • Women almost always postmenopausal
  • Classically monoarticular LE podagra (50), (vs
    pseudopodogra) gtankle gtgonagra gtupper extremity.
  • Proximal joint, central arthropathy uncommon

9
Diagnosis
  • Evidence-based medicine based on EULAR (ESCISIT)
    10 key points
  • Acute attack 6-12 peak intensity with S/W/E/T
  • Aspiration always recommended if possible
  • Prompt polarized microscopic analysis performed
  • Definitive Dx requires crystal confirmation
  • Gout and Sepsis can coexist fluid should be
    sent Grams stain, culture
  • Serum uric acid levels neither confirm nor
    exclude gout
  • Radiographs not necessary
  • Risk factor assessment

10
ACUTE GOUT
  • THERAPY (for all crystal diseases)
  • Corticosteroids intrarticular gt systemic
  • NSAIDs fast acting full dose if no
    contraindications
  • Colchicine (PO,IV route dangerous)
  • narrow therapeutic window
  • Bone marrow suppression, myopathy, neuropathy
  • purgative effects Pt often run before they
    walk
  • ACTH
  • NEVER ALLOPURINOL

11
Intercritical Period
  • 70 prevelance of MSU crystals remain in the
    joint
  • Lasts months to years for 75-80, 20 never have
    another attack

12
Uric Acid Lowering Therapy
  • Lifestyle, dietary modification
  • Diet high in vegetables, dairy, water beneficial
  • Initiate uric acid lowering therapy after 1(?)
    or 2 episodes of acute gouty arthritis
  • Always prophylaxis for first 6 months with low
    dose steroids, NSAIDs, or colchicine

13
URICOSURICS
  • Uricosurics
  • probenecid 1-3 grams / day
  • sulfinpyrazone 200-400 mg / day
  • Benzbromarone 100-200 mg / day (not available)

14
URICOSURICS
  • Contraindications
  • Tophi
  • CRI (GFR gt35ml/min)
  • H/O urolithiasis
  • Intolerance
  • Rapid cell turnover states
  • 25 failure rate mild CRI
  • Interact with ASA, NSAIDs, PCN, captopril
  • Watch for rash , GI,HA, dyscrasias,nephrosis

15
Uricostatic Drugs
  • Allopurinol - developed 1957
  • Reduce annual gout attacks 4.4 to .06 / yr
  • Gradual resolution of tophi w/ uric acid lt 6
  • Titrate dose up to 600 mg /day
  • Uncreased toxicity with CRI
  • Allopurinol hypersensitivity rxn rare but can be
    fatal
  • Densensitization can be useful for mild SEs
  • Oxypurinol is an option but 50 intolerance
  • Multiple interactions imuran, 6MP, warfarin,
    theophylline, ampiciliin, diuretics
  • Treatment is lifelong

16
URICOSTATICS
  • FEBUXOSTAT
  • Not yet FDA approved
  • ?? Hepatic toxicity, HA, diarrhea
  • 80-120 day safer, more effective
  • No dose reduction for renal, hepatic
    insufficiency
  • Combination uricourics and uricostatics offer
    additional benefit
  • URICASE converts uric acid to allantoin
  • Recombinant uric acid oxidase RASURICASE
  • parenteral route can be given only once due to
    antibody production
  • Black box warning anaphylaxis, hemolysis,
    methemoglobinemia
  • Pegylated preparation approved for urate
    nephropathy in tumor lysis syndrome.
  • Expensive
  • Sq administration
  • Fenofibrate, Lozartan
  • E3040 new class of antiinflammatory compounds
  • Y-700, scopoletin

17
CHRONIC GOUT
  • USUALLY PRESENT AFTER 10 YEARS OF ACUTE
    INTERMITTANT GOUT
  • TOPHI DEPOSITION
  • CHRONIC SWOLLEN JOINTS
  • JOINT DESTRUCTION
  • ABSOLUTELY REQUIRES ALLOPURINOL

18
CHRONIC GOUT
19
CPPD DISEASE
20
CPPD Presentations
  • Acute Pseudogout
  • Positive birefringent rod shaped crystals
  • More likely in OA joint kneegt wristgt MCPsgt
    hips,shoulders,ankles
  • Pseudo-rheumatoid pattern
  • Osteoarthritis with/out pseudogout
  • Chondrocalcinosis
  • Neuropathic joint
  • Tumoral CPPD deposition

21
CPPD Presentations
  • Acute Pseudogout
  • Positive birefringent rod shaped crystals
  • More likely in OA joint kneegt wristgt MCPsgt
    hips,shoulders,ankles
  • Pseudo-rheumatoid pattern
  • Osteoarthritis with/out pseudogout
  • Chondrocalcinosis
  • Neuropathic joint
  • Tumoral CPPD deposition

22
CPPD Presentations
  • Acute Pseudogout
  • Positive birefringent rod shaped crystals
  • More likely in OA joint kneegt wristgt MCPsgt
    hips,shoulders,ankles
  • Pseudo-rheumatoid pattern
  • Osteoarthritis with/out pseudogout
  • Chondrocalcinosis
  • Neuropathic joint
  • Tumoral CPPD deposition

23
PSEUDOGOUT
  • HYPERPARATHYROIDISM
  • HEMOCHROMATOSIS
  • HYPOTHYROIDISM
  • HYPOMAGNESIEMIA
  • HYPERCALCEMIA
  • HYPOPHOPHATASIA

24
CPPD Associations
  • Chondrocalcinosis
  • Heriditary (rarely )

25
Basic Calcium Phosphate BCP Dz
  • Usually in the form of hydroxyapatite
  • Age related arthropathy except for pseudopodagra
    in young women
  • Milwaukee Shoulder
  • Calcific Periarthritis
  • Soft tissue calcification
  • Osteoarthritis (found in 70 of OA synovial fluid)

26
BCP Long-Term Treatment
  • ? Role for bisphosphonates
  • ? Role for low dose warfarin
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