GOUT

Question 1

Gout

Answer 1

Gout is a common form of inflammatory arthritis characterised by:
- raised uric acid concentration in the blood (hyperuricaemia)
- deposition of urate crystals in joints and other tissues.

Question 2

Gout - causes

Answer 2

1. High purine diet (which are metabolised to uric acid)
   - Seafood
   - Red meat
   - Kidneys, liver (from meat)
2. Alcohol intake
3. Dehydration
   - Due to not being able to clear uric acid
4. Certain medication
5. Overweight

Question 3

Drugs that cause hyperuricaemia i.e. gout

Answer 3

Diuretics (Loop + Thiazide)
Ciclosporin
Tacrolimus
Cytotoxic
Cancer

Question 4

Acute gout - treatment

Answer 4

1. NSAIDs
2. Colchicine
3. CS
4. Canakinumab

Question 5

NSAIDs- CI

Answer 5

• HF due to water retention
• Anticoagulants - increased bleeding risk
• Peptic ulcer
• Asthma
• ACEi

Question 6

NSAIDs

Answer 6

Diclofenac or Naproxen
Aspirin is NOT indicated in gout.
Continue for 1-2 days after attack has resolved
+ PPI

Question 7

Colchicine

Answer 7

• Alt in pt who are CI NSAIDS
• OK in HF and anticoagulants

Question 8

Colchicine - dose

Answer 8

• Colchicine: 500 mcg 2-4 times max 3 days - do not repeat course within 3 days

Question 9

Colchicine - narrow therapeutic index

Answer 9

• Toxic at high doses

Question 10

NSAIDs - interaction with diuretics

Answer 10

• NSAIDs induces fluid retention (interaction with diuretics)
• Colchicine preferred

Question 11

Colchicine - interactions

Answer 11

CYP3A4 inhibitors

Question 12

If NSAIDs or colchicine are unsuitable

Answer 12

• Short course of oral corticosteroid
• intra-articular [unlicensed use] or intramuscular injection of a corticosteroid or canakinumab can be considered.
• Joint aspiration may also be considered in certain patients with acute monoarticular gout (under specialist guidance).

Question 13

PO corticosteroids

Answer 13

Off-labeL use
Short course (3-5 days)
30 - 35 mg OD

Question 14

When is chronic treatment for gout offered?

Answer 14

Offered in frequent acute attacks of gout (2+ in a year)

Question 15

Gout - chronic treatment

Answer 15

Uric acid may be reduced with xanthine-oxidase inhibitors
1. Allopurinol
2. Febuxostat

If acute attack happens during treatment, continue chronic treatment swell as treating the acute attack separately

Question 16

Allopurinol - side effects

Answer 16

rash
discontinue - if mild restart carefully but discontinue immediately if recurrent

Question 17

Allopurinol - counselling

Answer 17

take w food

Question 18

Allopurinol - interactions

Answer 18

• ACEi
• TLD
  azathioprine
  mercaptopourine
• reduce the dose of aza/merc by 1/4 to 1/2 with allopurinol
• Increased risk of toxicity

Question 19

Febuxostat - side effects

Answer 19

Serious hypersensitivity reactions
Anaphylaxis
SJS
Check liver function
Caution in pre-existing CVD (allopurinol is the drug of choice)

Question 20

Uricosuric drugs

Answer 20

Sulfinapyrazone
Side effects:
- Makes urine alkaline
- Ensure adequate renal function/urine output
- Drink adequate to prevent crystallisation or urate in the urine

Question 21

Uricosuric drugs - interactions

Answer 21

Aspirin

Question 22

Renal impairment and long term therapy

Answer 22

Avoid uricosuric drugs
Allopurinol OK

Question 23

Important points

Answer 23

Never star during an acute attack
- Start preventative treatment 2-4 weeks after acute attack has resolved.
- If acute attacks are more common, may start earlier/during.

Initiation may precipitate an acute attack
- Use NSAID/Colchicine for 1 month after hyperuricaemia corrected

If an attack occurs during prophylaxis
- Continue as normal
- Treat attack separately