Internal Medicine

0521779407-C04 CUNY1086/Karliner 0 521 77940 7 June 14, 2007 20:37

434 Crystal-Induced Arthritis

differential diagnosis

■Septic arthritis: aspirate & culture the joint, treat w/ antibiotics until

results are known

■Calcium pyrophosphate deposition disease often co-exists w/

osteoarthritis, disordered calcium metabolism

■Polyarthritis of subacute or chronic crystal-induced disease may be

confused w/ rheumatoid arthritis, spondyloarthropathies

management

What to Do First

■Aspirate the joint for synovial fluid culture & crystal identification

General Measures

■Put joint at rest

■Pt education: encourage weight loss, decreased alcohol intake

specific therapy

Acute Attack

■High-dose NSAID

OR

■Oral colchicine, no more than 3 doses 1 hr apart

OR

■IV colchicine (single injection)

OR

■Intra-articular injection of triamcinolone hexacetonide

OR

■Oral corticosteroid tapering from 40 mg prednisone quickly: the best

choice when preceding ones are relatively contraindicated

Preventing Intercurrent Attacks

■Oral colchicine twice daily

OR

■Moderate-dose NSAID

Chronic Treatment for Elevated Uric Acid and/or Tophi

■Allopurinol, titrated to dose producing serum uric acid of <6.0 mg/dL

■If allopurinol is not tolerated: probenicid; increase monthly until uric

acid is normal

For CPPD disease, correct underlying metabolic abnormality

Side Effects

■NSAIDs: generics (ibuprofen, naproxen, sulindac) are as effective as

selective COX-2 inhibitor celecoxib but cause serious GI bleeding