Gout

Question 1

What type of crystal in Gout?

Answer 1

• monosodium urate crystals

Question 2

Will you treat isolated asymptomatic hyperurecemia?

Answer 2

• has to be really high > 6.8 mg/dL

Question 3

Risk Factor

Answer 3

• Hyperuricemia
• Gender: male 3X
• PostMenopausal female
• Fam hx
• Obesity, Wgt gain
• HTN
• Diuretic use
• ETOH use
• High sugar sweetended soft drink, fructose, sesafood, red meat, dairy product

Question 4

Dx of Gout

Answer 4

• Gold standard: urate crystals in synovial fluid analysis or in tophus by polarized light microscopy
• Alternative, clinical: classical clinical features such as podagra, tophi, rapid response to colchicine and/or characteristic imaging findings

Question 5

What are the characteristics of Xray finding of gout?

Answer 5

• Asymmetric swelling with acute gout
• Prominent, proliferative bony reaction
• Bone destruction away from joint may be caused by tophi
• Characteristic “overhanging edge” or “rat bite” of proliferating bone surrounding erosion may be present
• Gout less likely to cause joint space narrowing than psoriatic arthritis or RA

Question 6

How quick you should see response of treatment for acute gout?

Answer 6

> 20% improvement within 24 hours

> 50% improvement after 24 hours

Question 7

Pharm Rx for acute gout attack

Answer 7

• NSAIDs
• Colchicine
• Corticosteroids

Question 8

Non-Pharm mgt of gout

Answer 8

• rest and elevate affected joints
• keep bedclothes from inflamed joint with “bed cage”
• ice packs may reduce pain in acute gouty attacks

Question 9

Aborting acute gouty attack - if pain mild to moderate, affecting only 1-2 small or large joints

Answer 9

• monotherapy with po NSAIDS, systemic corticosteorids, or oral colchicine
• consider intra-articular corticosteroid

Question 10

Aborting acute gouty attack - if pain severe, affecting multiple joints

Answer 10

• full doses of colchicine and an NSAID
• full dose corticosteroid and colchicine
• intra-articular steroid with any other treatment

Question 11

How about use of colchicine?

Answer 11

• Antigout and antimitotic agent
• Recommended to use as quickly as possible after acute onset for reducing pain and inflammation
• Treat until attack terminates, 1-2 weeks
• do not use oral colchicine if patient has been treated with acute gout regimen in past 14 days
• Avoid in elderly > 75 yo, b/c high risk of diarrhea and dehydration

Question 12

Gout acute treatment in elderly

Answer 12

• NSAID and corticosteroids

- NO colchicine b/c risk of diarrhea and dehydration

Question 13

How to choose NSAID for gout?

Answer 13

• fasting acting one at max dose for short term
• NSAIDs used more frequently than colchicine, but direct comparisons between NSAIDs and colchicine lacking
• PO
  // Indomethacin 50 mg tid qd
  // Naproxen 750 mg, then 250 mg q8hr
  // Sulindac, Celecoxib

Question 14

Rx to prevent recurrent attack of gout?

Answer 14

• Urate-lowering therapy: Xanthine oxidase inhibitor: allopurinol or febuxostat
• Anti-inflammatory prophylaxis: 6 mo, colchicine 1st line, NSAIDs or prednisone (as second line)

Question 15

What’s the role of uricosuic drugs?

Answer 15

• 2nd line in prevention
• CI in patient with uric acid overproduction or overexcretion
• Probenecid, Sulfinpyrazone
• Other drugs with uricosuric property: losartan, fenofibrate, atorvastatin

Question 16

What’s the role of uricolytic enzyme?

Answer 16

for severe gout refractory to conventional urate-lowering therapy

Question 17

What’s the target uric acid level?

Question 18

What needs to be monitored?

Answer 18

• Plasma urate level

- Creatinine level