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Gout Management
Pharmacotherapy for gout management
| Question | Answer |
|---|---|
| What are the risk factors for developing gout? | Age, renal disease, obesity, male, metabolic disorders like hypertension and insulin resistance, medication (thiazide diuretics, cyclosporin, nicotinic acid, levodopa, low dose aspirin) |
| What are the signs and symptoms of gout? | Sudden onset of monoarticular arthritis (common in first metatarsophalangeal joint), rapid onset of pain or redness in the affected joint(s), |
| Gout most commonly occurs in the big toe, where else can it occur? | Feet, knees and hands |
| What is the first type of gout attack? | Acute gouty arthritis: first attack is monoarticular (80% in big toe, 10% in polyarticular -ankles, DIP joint, elbows, knees) Severe pain in joint, red, hot, swollen and very tender, resolve with drug treatment, variable remission periods |
| What can happen if an acute gout attack isn't treated? | Risk of permanent deformity |
| What is the second type of gout attack? | Chronic tophaceous gout: Tophi (uric acid crystal aggregates) deposits in joints Ongoing low grade inflammation, joint deformity |
| What is the third type of gout attack? | Gout nephropathy: deposits of uric acid crystals in renal tubules mononuclear cell infiltration, fibrosis, proteinuria and/or renal impairment |
| What is the aim of treating an acute gout attack? | Reduce inflammation, relieve pain, and shorten duration of attack. Commence treatment within 24 hours of symptoms onet |
| What is the aim of treating chronic hyperuricaemia? | Reduce serum levels to prevent acute attacks and joint destruction, disability, nephrolithiasis and renal disease |
| What should be done in treating acute and chronic gout? | Minimise exacerbating factors, including medicines used to treat comorbidities (low dose aspirin and thiazide duretics) |
| What are the non-pharmacological steps in managing gout? | Weight loss, reduce alcohol intake (esp. beer), decrease animal offal, seafood (shell fish, anchovies, sardines -limited evidence), decrease soft drinks and fruit juices (avoid fructose) |
| How is acute gout treated? | Nsaids first line if not C/I Indomethicin and naproxen -aspirin isn't used, pre-existing low dose aspirin isn't stopped |
| When is colchicine used ina cute gout treatment? | If nsaids or corticosteroids are contra-indicated. Caution in hepatic or renal impairment patients |
| What is the dose of colchicine? | 1mg initially, then 0.5mg 1 hour later (max 1.5mg per course). Do not repeat within 3 days |
| What else can be used with colchicine to give pain relief? | Paracetamol |
| When is colchicine most effective? | If given early |
| When are corticosteroids given in an acute gout attack? | When NSAIDS or colchicine are C/I (renal failure, heart failure, anticoagulated patients) |
| What is the dose of prednisolone for acute gout? | 15-20 mg d for 3-5 days |
| What are the ADR's of colchicine? | Blood dyscrasias, GI effects, peripheral neuropathy, risk of myelosuppression in renal disease (extend interval between doses to two weeks in event of) |
| What types of drugs can cause colchicine toxicity? | CYP3A4 inhibitors - gradefruit juice, erythromycin, verapamil, diltiazem, protease inhbitors |
| What class of drugs if used with colchicine can cause rhabdomyolysis? | Statins |
| When should urate lowering therapy (gout prophylaxis) be considered? | Tophi, two or more gout attacks in last 12 months, chronic kidney disease (stage 2 or worse), urolithiasis |
| What are the drugs used for long term urate lowering therapy? | Allopurinol, febuxostat, probenecid |
| What is the mantra with dosing in long term urate lowering therapy? | Start low, go slow Do not stop during an acute gout attack if patient has already started urate lowering therapy. |
| Which drug is first line for urate lowering therapy? | Allopurinol |
| What is the dose of allopurinol for ULT? | 100mg d to start with and treat to target (dose range is 300mg to 900mg d) |
| What is the dose of allopurinol in a patient with renal impairment (eGFR below 30ml/min)? | 1.5mg per mL of eGFR |
| What is the target serum uric acid if tophi are present? | Less than 0.30mmol/L 0.36mmol/L in all other patients |
| What are the ADR's of allopurinol? | Acute gout attack, hypersensitivity reactions, hepatotoxicity, altered taste, drowsiness, nausea, diarrhoea |
| True or flase: allopurinol can be started during an acute gout attack if acute gout treatment haas been started? | True |
| What are the precautions for allopurinol? | Patients of Asian ethnicity and previous hypersensitivity reactions |
| When is febuxostat used in ULT? | Alternative to allopurinol |
| What are the precautions for febuxostat? | IHD, hear5t failure, hypersensitivity to either allopurinol or febuxostat, CrCl below 30 ml/min, hepatic impairment |
| What is the dose for febuxostat? | Start 40mg once d Review serum urate at 2-4 weeks, if serum urate below 0.36mmmol/l then increase dose to 80mg once d |
| What is the dose equivalence of febuxostat to allopurinol? | 40mg febuxostat is clinically equivalent to 300mg allopurinol |
| What are the ADR's of febuxostat? | Acute gout attack, hypersensitivity, hepatotoxicity |
| When is probenecid C/I? | In patients with kidney stones |
| True or false: probenecid can be initiated during an acute gout attack | False |
| What is the dose of probenecid for ULT? | Start at 250 mg bd for 1 week, then treat to target. Maintenance dose is 500mg - 2 g total daily dose |
| What are the ADR's of probenecid? | Rash, nausea, uric acid kidney stones - can be prevented by ensuring adequate fluid intake |
| Probenecid can intract with aspirin, does this include low dose aspirin? | No |
| Why is prophylactic treatment used when introducing ULT? | Increased risk of acute gout attack when starting ULT, and when changing the dose. |
| What drug are used for prophylactic treatment when starting ULT? | Colchicine - low dose 0.5mg d or bd NSAIDS - indomethacin 25mg bd or naproxen 250 mg bd for atleast six months (both) |
Created by:
LDM
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