drug pseudogout

good evening, so im going to start we're goingto do gout today. alright now there are a few graphic pictures later on but i will prepareyou before you see them. so, this lecture is actually meant to tell you what gout is.we’re going to go through the medications as well, those that we use for treatment andalso to explain why starting medications are so important. i want to emphasize that thislectures meant to be educational, it is not a substitute for treating yourself as well.now you need to consult with your medical provider to discuss current medications andof course you need to take your prescribed medications under the direction of your physicianas well. you'll see when i go through the different medications that many of these arechosen on an individual basis based on other

medications you're on based on your othermedical problems as well. so that's why it’s important that even though were going to gothrough all of this stuff that you go to your primary care doctor. so this is gout, a lotof patients will agree that this is how it feels more like gouch. its cause by a depositionof these crystals know as monosodium urate crystals. it comes from an elevated uric acidlevel in the blood and uric acid is increased because over production. it can also be causedby impairment in the kidneys to actually remove it from the blood. additionally which wasn'tmentioned in the small spot but you'll see later on it can actually be caused by geneticpredisposition some patients just get it. the inverse is that not everyone with a highuric acid developed gout as well. there may

be individual differences between how oneperson responds to an increased uric acid level as opposed to the other. some peopleactually are most receptacle to the inflammation and therefor they have more joint pain asoppose to others. who is most at risk? males, patients with advanced age and the simplereason is because as you get older the kidney filters out things differently. now this mayseem counter intuitive. initiation of allopurinol or uloric which is the actual medication.now i try to explain to patients that what happens is when we first start the medication,you’re trying to remove the uric acid so sometimes what happens is that as there'sa change in how the uric acid is being disposed of it can actually induce a gout attack. veryodd but yes it does happen. and you’ll see

that sometimes when we stop allopurinol rheumatologistor uloric which is very similar to this. we start- to prevent a gout attack while theallopurinol is trying to lure the uric acid. so trauma surgery can also cause it, starvation,fatty foods or overindulgence does increase the risk of gout. dehydration, alcohol particularlybeer and ingestion of drugs which actually increase uric acid. one example of the diureticsfor example loop diuretics or thiazides such as lasixs or hydrochlorothiazide, low doseaspirin sometimes, even insulin in the beta blockers and the reason they do this becausethey change how the kidney is able to get rid of the uric acid. one thing you must keepin mind is that even though these medications cause this we do not discourage the use ofthem for example if a patient has risk factors

for cardiovascular disease and you have gout,sometimes it makes more sense to be on the aspirin to be on the diuretic as well forblood pressure control and then we just control the gout on the side. some patients ask whyit is the big toe that sometimes gets involved. and it’s often related to the coolness anddecreased liability of the crystals in the area that’s why patients get gout in thebig toe. sometimes they think it’s because of micro trauma and some patients dissolvecrystals in different ways. so that’s why it tends to happen there. the different syndromesand you’ll see that some patients actually they go in between these different phasesrather. there's acute gout which is of course the acute attack which is extremely exquisitelypainful. then you also have an inter critical

period and this is the period in between attacksand hopefully this last indefinitely once you end medication. now here youll see a graphicpicture on what as know as tophi. these are actually uric acid crystals, that have actuallyposited within the joints and this is of course someone who had a severe form of gout. ifyou go untreated or if you're not appropriately treated with enough medication then this canactually happen when you continue to have chronic recurrent accumulation of uric acidand pain. how does it present? all of you who have had gout attacks know it’s seversevere pain. one of the things we learned in medical school is that a patient can’teven allow a bed sheet to even touch their foot particularly when it happens that's howsevere the pain is. there is swelling theirs

redness there's disability you can’t movethe joint and usually it tends to have maximum severity in about 12 top 24 hours and goutactually does resolve by its self with a reason we of course treat is because of that previoushand that i actually showed you. it tends to resolve cause its a crystal, so the bodyfinds a way to actually dissolve it gradually. 80% of the initial attacks happen in the bigtoe or even the knee. it can happen in the hands, wrist, elbows, ankles all of theseplaces particularly of you're not treated and you continue to have more and more attacks.how does it look? so you see some patients actually, it can be very benign. sometimesjust one wrist sometimes you just have a small tophi which is that accumulation which i showedyou and this is the uric acid coming out and

then sometimes this is how bad it can happen.yes this is rare but this is what it can progress to and ive seen this with some patients. thishere is of course severe gout and tophi and here you actually see destruction of the bonecause by the the uric acid entering these joints and just essentially just eating awayat these areas over here. what do we do when we see a patient? we do, do lab test of courseif new hospital you get the white blood cell count, we do the esr and crp which shows iftheres active inflammation. some patients however have a normal uric acid and the besttime actually to get this done is about 2 weeks after the attack. so the new ways ofdiagnosing gout and we have new recommendations which ill go through but the best way to actuallydiagnose is to get fluid from that painful

joint and to look for the crystal and illeven show you what that looks like later on. the reason we actually emphasis of gettingthe fluid is so important because so many things can actually mimic, because you cansee how non specific it can be you can get just one wrist it can be just one toe, itcan be both knees both wrist. osteoarthritis, pseudo gout which is actually another jointdisease caused by another crystal can also present some