When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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CommonRheumatology

Acute Gout & Pseudogout

Crystal arthropathies -the most common inflammatory arthritis. Gout = monosodium urate (negatively birefringent needles). Pseudogout = calcium pyrophosphate (positively birefringent rhomboids). Joint aspiration is the gold standard -don't guess, tap.

🔍 Overview

Gout vs Pseudogout

Feature	Gout	Pseudogout (CPPD)
Crystal	Monosodium urate (MSU) -needle-shaped, negatively birefringent (yellow when parallel to polarizer)	Calcium pyrophosphate (CPP) -rhomboid-shaped, positively birefringent (blue when parallel)
Classic joint	1st MTP (podagra) -also ankles, knees, wrists	Knee (#1), wrists, shoulders
Demographics	Men > women (until menopause). Obesity, alcohol, purine-rich diet, CKD.	Elderly (> 65). Associated with hemochromatosis, hyperparathyroidism, hypomagnesemia, hypothyroidism.
X-ray	Erosions with overhanging edges ("rat-bite"), tophi (late)	Chondrocalcinosis (calcification of cartilage -menisci, triangular fibrocartilage of wrist)
Serum uric acid	Often ↑ but can be normal during acute flare (~40%). Do NOT rule out gout based on normal UA.	Normal

Always rule out septic arthritis first. Gout and septic arthritis can look identical (hot, swollen, painful joint with leukocytosis). Septic arthritis is joint-threatening → tap the joint. Crystal-positive fluid does NOT rule out concurrent infection -they can coexist.

💊 Management

Acute Flare Treatment

Drug	Dose	Notes
NSAIDs 1ST LINE	Indomethacin 50 mg TID × 5–7 days, or naproxen 500 mg BID	Most effective if started within 24h. Avoid in CKD, GI bleed, CHF, anticoagulation.
Colchicine (Colcrys) 1ST LINE	1.2 mg PO, then 0.6 mg 1h later (total 1.8 mg day 1). Then 0.6 mg BID until flare resolves.	Low-dose colchicine (AGREE, 2010) is as effective as high-dose with far fewer GI side effects. Best within 36h of onset. Reduce dose in CKD. Avoid with strong CYP3A4 inhibitors (clarithromycin).
Corticosteroids IF NSAIDs/COLCHICINE CI	Prednisone 30–40 mg/day × 5 days (or taper over 10–14 days). Or intra-articular triamcinolone if 1–2 joints.	Preferred in CKD, GI disease, or elderly. Intra-articular injection is ideal for monoarticular flare (after ruling out septic joint).
IL-1 inhibitor (anakinra) REFRACTORY	100 mg SC daily × 3–5 days	For patients who fail or cannot take NSAIDs, colchicine, AND steroids. Off-label but effective. anaGO, 2021

Urate-Lowering Therapy (ULT) -Chronic

🔄 Starting ULT during an acute flare CHANGED
Old teaching: never start allopurinol during a flare, it will prolong the attack. Current practice (ACR 2020, conditional): it IS safe to start urate-lowering therapy during an acute flare, provided anti-inflammatory cover (colchicine 0.6 mg daily or BID, NSAID, or low-dose prednisone) is on board. Multiple RCTs show no increase in flare duration or severity. Why the change: delaying ULT by weeks creates treatment gaps and patients are lost to follow-up. Never stop ULT if the patient is already on it during a flare, abrupt urate shifts worsen the attack.

Drug	Dose	Notes
Allopurinol (Zyloprim) 1ST LINE	Start 100 mg daily (50 mg if CKD), titrate by 100 mg q2–4 weeks. Target: serum urate < 6 mg/dL.	Preferred ULT in patients with CV disease (post-MI, CAD, prior stroke), allopurinol had lower CV mortality and all-cause mortality vs febuxostat in CARES, 2018. *Check HLA-B5801 before starting in Southeast Asian, Black, and Korean patients**, risk of severe hypersensitivity (SJS/TEN/DRESS). Start low, go slow.
Febuxostat (Uloric) 2ND LINE	40–80 mg daily	AVOID in patients with CV disease (post-MI, CAD, prior stroke). CARES, 2018: febuxostat had higher CV mortality (HR 1.34) and all-cause mortality (HR 1.22) vs allopurinol, leading to an FDA black-box warning. Reserve for: patients who fail allopurinol, are HLA-B*5801 positive, or have severe allopurinol intolerance.

Indications for ULT (ACR 2020): Strong recommendation: ≥ 2 flares/year, ≥ 1 subcutaneous tophus, or radiographic damage from gout. Conditional recommendation (start ULT after even 1 flare if): CKD stage ≥ 3, serum urate > 9 mg/dL, or urolithiasis (urate stones). Target serum urate < 6 mg/dL (< 5 if tophi). Why titrate to a number, not symptom relief: below the urate saturation point (~6.8 mg/dL) crystals dissolve and tophi shrink. Treating to target is what prevents recurrent flares and joint erosion; treating only until the patient feels better leaves crystals in place and the next flare is coming.

Related Topics

Antiphospholipid SyndromeDermatomyositis & PolymyositisPMR & Giant Cell ArteritisRheumatoid ArthritisScleroderma & Renal CrisisSeronegative Spondyloarthropathies

🧪 Workup

Workup

Joint aspiration -gold standard. Negatively birefringent, needle-shaped monosodium urate crystals under polarized light. Yellow when parallel to compensator.
Synovial fluid WBC -2,000-50,000 (inflammatory range). ALWAYS send culture + gram stain -gout and septic arthritis can coexist (up to 5% of gout flares).
Serum uric acid -can be NORMAL during acute flare (don't use to diagnose). Check between flares for ULT target. Flare threshold usually > 6.8 mg/dL (supersaturation point).
BMP + Cr -renal function determines medication choice (colchicine dose, allopurinol starting dose). CKD is both a cause and consequence of hyperuricemia.
CBC -leukocytosis during flare (mimics infection)
HLA-B*5801 -BEFORE allopurinol in Southeast Asian, African American, Hawaiian/Pacific Islander patients. Strong predictor of DRESS/SJS. If positive → use febuxostat instead.
24h urine uric acid -uric acid overproducer (> 800 mg/day) vs underexcretor. Guides ULT choice (xanthine oxidase inhibitor vs uricosuric).
X-ray -acute: soft tissue swelling only. Chronic: "rat-bite" erosions with overhanging edges, tophi. DECT: urate crystal deposition (research, not routine).

💊 Medications

Medications

Drug	Dose	Route	Notes
Acute Flare Treatment
Colchicine	1.2 mg → 0.6 mg at 1h (day 1), then 0.6 mg BID	PO	Low-dose regimen AGREE, 2010 -equally effective, far fewer GI side effects. Reduce dose if CrCl < 30 (0.3 mg BID). Onset within 24h.
Indomethacin	50 mg TID × 3 days, then taper	PO	NSAID -fast acting. Avoid in CKD, GI bleed, HF, anticoagulation. Naproxen 500 BID is alternative.
Prednisone	30-40 mg daily × 5 days	PO	If NSAIDs + colchicine contraindicated. Equally effective. No taper for 5-day course. Best for polyarticular flare.
Intra-articular triamcinolone	10-40 mg per joint	IA	Monoarticular flare -fast relief. Must rule out septic joint first (culture synovial fluid).
Anakinra	100 mg SQ × 3-5 days	SQ	IL-1 receptor antagonist. For refractory flares when ALL of the above are contraindicated (CKD + CHF + anticoag + infection).
Urate-Lowering Therapy (ULT) -Start ≥ 2 weeks after flare resolves
Allopurinol	Start 100 mg daily (50 mg if CKD), titrate by 100 mg q2-4 weeks	PO	Xanthine oxidase inhibitor. Target UA < 6 mg/dL. Max 800 mg. Check HLA-B*5801 first in at-risk populations. Titrate slowly -faster titration does NOT cause more flares. Allopurinol Dose-Escalation Study, 2017
Febuxostat	40-80 mg daily	PO	XOI alternative if allopurinol intolerant or HLA-B*5801+. More potent per mg. FDA CV warning but FAST, 2020 showed non-inferiority to allopurinol.
Probenecid	250 mg BID → 500 mg BID	PO	Uricosuric. Only if underexcretor. Contraindicated if CrCl < 50 or nephrolithiasis.
Pegloticase	8 mg IV q2 weeks	IV	Recombinant uricase. Refractory tophaceous gout only. Must premedicate. Check UA before each infusion -if > 6, discontinue (loss of response → anaphylaxis risk).

Flare prophylaxis when starting ULT: colchicine 0.6 mg daily × 3-6 months. Starting ULT mobilizes urate crystals from deposits → paradoxical flares. Do NOT stop ULT during a flare -it does not worsen flares and stopping/starting destabilizes urate levels.

📋 On Rounds

Why can serum uric acid be normal during an acute gout flare?

During an acute inflammatory response, IL-6 increases renal urate excretion via uricosuric effects and redistributes urate from plasma into tissues. Additionally, the acute phase response and volume shifts during inflammation dilute serum urate. Up to 40% of acute gout flares have a normal serum uric acid. This is why a normal UA does NOT rule out gout -you need joint aspiration with polarized microscopy (negatively birefringent crystals)

A patient with gout is already on allopurinol. Should you stop it during an acute flare?

NO -do NOT stop allopurinol during an acute flare. This is one of the most commonly made errors. Stopping or starting ULT (urate-lowering therapy) during a flare causes uric acid fluctuations that can prolong and worsen the flare. If the patient is already on allopurinol, continue it at the same dose and treat the flare with NSAIDs, colchicine, or steroids. If ULT hasn't been started yet, wait until the flare resolves (2–4 weeks)

What is the treat-to-target approach for uric acid, and what level do you aim for?

Target serum uric acid < 6 mg/dL (or < 5 mg/dL if tophi present). The monosodium urate saturation point is ~6.8 mg/dL -keeping UA below 6 ensures crystals dissolve over time and prevents new deposition. Treat-to-target protocol: Start allopurinol low (100 mg daily, or 50 mg if CKD) → increase by 100 mg every 2-4 weeks → check UA level → keep titrating until UA < 6. Most patients need 300-600 mg daily (not the old default of 300 mg).

What is the role of IL-1 inhibitors in gout?

Anakinra (IL-1 receptor antagonist) is used for acute gout flares when NSAIDs, colchicine, AND steroids are all contraindicated or failed -typically in patients with CKD + HF + active infection (can't use NSAIDs, colchicine, or steroids safely). Dose: 100 mg SQ daily × 3 days. Works by blocking IL-1β, which is the key cytokine released when NLRP3 inflammasome is activated by MSU crystals.

A patient has an acute gout flare. Should you start allopurinol now?

Current guidelines say you CAN start ULT during a flare [ACR 2020] -it does not worsen or prolong the flare. But always add flare prophylaxis (colchicine). Never STOP ULT during a flare -stopping/restarting destabilizes urate levels.

Why do you check HLA-B*5801 before starting allopurinol?

HLA-B*5801 is a strong predictor of severe allopurinol hypersensitivity (DRESS/SJS/TEN) -fatality rate ~25%. Prevalence: 6-8% in Southeast Asian, 3.5% in African American. If positive → use febuxostat instead.

What is the serum urate target for gout ULT?

< 6 mg/dL (below the supersaturation point of 6.8 mg/dL). For severe tophaceous gout, target < 5. It takes 6-12 months of sustained target to dissolve tissue urate deposits.

Clinical Examples

📋 Case 1, Acute Gout in CKD

Patient: 68-year-old man with CKD stage 4 (GFR 22), HTN, and no prior gout history presenting with acute right knee swelling, erythema, and severe pain × 1 day. WBC 14,000. Temp 38.1°C.

Key findings: Arthrocentesis: WBC 38,000, negatively birefringent needle-shaped crystals. Gram stain negative, culture pending. Serum uric acid 6.4 (normal, does not rule out gout). Cr 3.8 at baseline.

Management:

NSAIDs and high-dose colchicine both contraindicated (CKD 4)
Prednisone 30 mg PO daily × 5 days (preferred in CKD when infection excluded)
Intra-articular triamcinolone 40 mg, ideal for monoarticular flare after ruling out septic joint
Continue culture follow-up, gout and septic arthritis can coexist (5% of cases)

Teaching point: In CKD, steroids (PO or intra-articular) are the safest option. Normal uric acid during a flare occurs in ~40% of cases due to IL-6-mediated uricosuria, never use it to rule out gout.

📋 Case 2, ULT Initiation with Mobilization Flare

Patient: 55-year-old man with 4 gout flares in the past year, tophi on bilateral elbows. UA 9.2 mg/dL between flares. HLA-B*5801 negative. Started allopurinol 100 mg daily 3 weeks ago with colchicine 0.6 mg daily prophylaxis. Now presents with acute left 1st MTP flare.

Key findings: This is a mobilization flare, expected when starting ULT as tissue urate deposits dissolve and crystals are released into joints. UA trending down to 7.4 (not yet at target).

Management:

Do NOT stop allopurinol, stopping/restarting destabilizes urate levels and worsens outcomes
Treat the acute flare: colchicine 1.2 mg then 0.6 mg in 1h, then resume 0.6 mg BID AGREE, 2010
Continue uptitrating allopurinol by 100 mg q2-4 weeks → target UA < 5 mg/dL (tophi present)
Continue colchicine prophylaxis × 6 months after reaching target

Teaching point: Mobilization flares are expected and do NOT mean ULT has failed, they mean urate is being cleared. Continue ULT, treat the flare, and reassure the patient.

📋 Case 3, Pseudogout Mimicking Septic Joint

Patient: 78-year-old woman with hypothyroidism presenting with acute right wrist swelling, warmth, and fever (38.5°C) × 2 days after a hospitalization for pneumonia. WBC 16,000. X-ray shows chondrocalcinosis of the triangular fibrocartilage.

Key findings: Arthrocentesis: WBC 45,000, positively birefringent rhomboid-shaped crystals (calcium pyrophosphate). Gram stain negative. No growth at 48h.

Management:

Acute CPPD flare (pseudogout), triggered by acute illness/hospitalization
Treatment same as gout flare: NSAIDs, colchicine, or steroids
Given age and recent pneumonia → prednisone 25 mg × 5 days
Check for metabolic associations: hypothyroidism (already known), hemochromatosis (ferritin, iron saturation), hyperparathyroidism (calcium, PTH), hypomagnesemia

Teaching point: Pseudogout is commonly triggered by acute medical illness or surgery. Unlike gout, there is no urate-lowering equivalent, treatment is limited to flare management. Always check for associated metabolic conditions, especially in patients under 60.

📣 Sample Presentation

One-Liner

"Mr. Thompson is a 62-year-old with CKD3 presenting with acute right first MTP joint erythema, swelling, and exquisite tenderness × 2 days. Joint aspiration shows negatively birefringent needle-shaped crystals. WBC 42,000 in synovial fluid. Acute gout."

Key Points to Cover on Rounds

Acute gout confirmed by crystal analysis. Septic joint ruled out (culture pending, but crystals identified -can coexist, treat empirically if concern). Treatment: colchicine 1.2 mg then 0.6 mg 1h later, then 0.6 mg BID (low-dose per AGREE, 2010 -less GI toxicity than traditional high-dose). NSAIDs avoided (CKD3). Uric acid level 7.8 (can be normal during flare). Already on allopurinol 200 mg -continued (don't stop during flare). Plan: after flare resolves → uptitrate allopurinol to target uric acid <6, continue colchicine 0.6 mg daily × 6 months as prophylaxis. Check HLA-B*5801 if not previously done.

Monitoring

Serum uric acid q2-4 weeks while titrating ULT -target < 6 mg/dL (or < 5 if tophi present). Most common error: starting at full dose. Always start low, go slow.
Cr + LFTs q3-6 months on allopurinol/febuxostat -rare hepatotoxicity, dose-adjust for CKD
CBC if on colchicine long-term (rare bone marrow suppression, especially with CKD or statin interaction)
Flare frequency -should decrease after 6-12 months of ULT at target. Early ↑ in flares is expected when starting ULT (crystal mobilization) -this is why prophylaxis is essential
Colchicine prophylaxis × 3-6 months when starting or titrating ULT (0.6 mg daily or BID). Prevents mobilization flares. Continue until urate at target for ≥ 3-6 months with no flares.
Tophi assessment -should shrink over 12-24 months on ULT. If persistent → urate not at target
Joint imaging -X-ray at baseline for erosions. Dual-energy CT if diagnostic uncertainty (research tool, not routine follow-up)

Monitoring Parameters -DIC

Parameter	Frequency	Target / Action
Vitals	q4h floor, q1–2h ICU	HR, BP, RR, SpO₂, Temp -notify for significant deviations
Labs (BMP, CBC)	Daily AM or as indicated	Trend Cr, K⁺, WBC, Hgb -adjust treatment based on trajectory
Disease-specific markers	Per clinical context	See Overview and Management tabs for condition-specific targets
I&Os	Strict if volume-sensitive	UOP ≥ 0.5 mL/kg/hr. Net fluid balance guides diuresis or resuscitation.
Telemetry	Continuous if indicated	Arrhythmia detection. Discontinue when no longer indicated (reduces alarm fatigue).
Clinical response	Each assessment	Symptom improvement, functional status, appetite, mental status -the exam matters more than labs

Don't just order labs -act on them. Every lab should have a clear clinical question. If you wouldn't change management based on the result, don't order it.

⚡ Summary

Summary

Acute Flare

Colchicine 1.2 mg → 0.6 mg 1h later → 0.6 BID (low-dose AGREE, 2010). NSAIDs. Steroids if both contraindicated. Anakinra for refractory.

Crystal Diagnosis

Joint aspiration: negatively birefringent needle-shaped crystals under polarized light. WBC 2,000-50,000. Culture to rule out concurrent septic joint.

ULT Goal

Treat-to-target: uric acid < 6 mg/dL (< 5 if tophi). Allopurinol start 100 mg, titrate by 100 mg q2-4 weeks. Check HLA-B*5801 in at-risk populations.

Don't Stop ULT

Continue allopurinol/febuxostat during acute flare. Stopping → rebound uric acid fluctuation → worsening flare.

Flare Prophylaxis

Colchicine 0.6 mg daily × 3-6 months when starting or titrating ULT. Prevents mobilization flares from urate crystal dissolution.

Pseudogout

Positively birefringent rhomboid crystals = CPPD (calcium pyrophosphate). Knee most common. Treatment: similar to gout. No ULT equivalent.

📄 One Pager

Rheumatology · One Pager

Gout

Crystal confirmation on aspiration. Acute: colchicine (low-dose) + NSAIDs + steroids. Chronic: treat-to-target uric acid < 6 with allopurinol. Check HLA-B*5801 in at-risk populations.

🧪 Diagnosis

Joint aspiration: negatively birefringent needle-shaped crystals under polarized light. Mono-inflammatory arthritis (1st MTP classic). WBC 2,000-50,000. Culture to rule out concurrent septic joint.

🚨 Acute Flare

Colchicine 1.2 mg → 0.6 mg at 1h → 0.6 BID (low-dose AGREE, 2010). NSAIDs (indomethacin or naproxen). Steroids if both contraindicated. Anakinra (IL-1 blocker) for refractory.

💊 Chronic -ULT

Target uric acid < 6 mg/dL (< 5 if tophi). Allopurinol: start 100 mg, titrate by 100 mg q2-4 weeks. Check HLA-B*5801 (Southeast Asian, African American -SJS/TEN risk). Flare prophylaxis: colchicine 0.6 mg daily × 3-6 months.

💊 Key Drugs

Colchicine1.2 → 0.6 mg (acute)

Allopurinol100-800 mg daily (titrate)

Febuxostat40-80 mg daily (if B*5801+)

Colchicine0.6 mg daily (prophylaxis)

⚠️ Pitfalls

Stopping ULT during acute flare (don't stop -continue and add anti-inflammatory)
Starting ULT without flare prophylaxis (colchicine × 3-6 months)
Not checking HLA-B*5801 in at-risk populations
High-dose colchicine (use low-dose -same efficacy, less GI toxicity)

🩺 Health Check