GOUT in practice Flashcards
what is the usual presentation of GOUT?
Rapid onset (usually 6-12h) severe pain, swelling,
redness, warmth, tenderness in joint
–Most commonly 1st metatarsophalangeal joint
–Also common midfoot, ankle, knee, fingers, wrist,
elbow
–Most commonly monoarticular
–Tophus (proven or suspected)
what are the differential diagnoses for GOUT?
- Pseudo-gout (non-urate crystal induced)
- OA
- RA
- Psoriatic arthritis
- Cellulitis
- Bursitis
- Tenosynovitis
- Trauma
- Haemochromatosis
what is septic arthritis?
suspect if systemically unwell and painful hot, swollen joint refer immediately for emergency joint aspiration and culture. Late recognition can be fatal.
what are the risk factors for septic arthritis?
- Age
- Male
- Renal impairment
- Hypertension
- Drug factors e.g. diuretics
- Tophi
- Chronic arthritis
- Alcohol consumption
when would you refer suspected GOUT to secondary care?
•if septic arthritis suspected (urgently)
•Unresponsive to uric acid lowering or persistent sx
despite max NSAIDs (routine)
•Complications relating to gout (e.g. neuropathy)
•Gout persists despite uric acid levels being lowered
•Young onset (<30yrs), pregnancy, diagnostic uncertainty
how do you manage GOUT?
•Start anti- inflammatory/analgesic straight away and continue for 1-2 weeks (24-48h after attack has resolved) •Elevate and rest affected joint, keep cool, avoid trauma to joint
what is the 1/2/3rd line treatments for GOUT?
1st line: NSAID full dose (or COX-2 inhibitor) + PPI or •2nd line: Colchicine •3rd line: Corticosteroids
does colchicine have a narrow or wide therapeutic index?
Narrow therapeutic index, very toxic in overdose
when is colchicine more effective?
More effective if taken within 12-24 hr of attack
what is the usual dose of colchicine?
500 micrograms 2-3 x day until symptoms relieved
(or diarrhoea/vomiting occurs)
Max dose 500mcg QDS can be used but often limited
by diarrhoea/toxicity
•Reduce dose/increase dose interval if elderly
what is the max dose you can give of colchicine?
Max 6mg per acute treatment course, don’t
repeat within 3 days.
what interactions occur with colchicine?
Use caution/low doses if concomitant CYP450 3A4
inhibitors e.g. clarithromycin, erythromycin,
tolbutamide, fluoxetine…
–Caution renal impairment + statin - reports of
myopathy and rhabdomylosis
when are corticosteroids used in GOUT?
Useful if can’t take NSAID/doesn’t tolerate colchicine
what corticosteroids are given in gout?
•Intra-articular injection(gouty monoarthritis only) –Methylprednisolone –hydrocortisone acetate –Triamcinolone Oral prednisolone •Oral prednisolone –E.g. 20-40mg daily for 5 days •IM injection –Methylprednisolone/ Triamcinolone
how would you acutely manage GOUT?
assess lifestyle factors- alcohol / decrease purine rich foods
treat cv risk factors
consider drug indiced GOUT
what could be possible examples of drug induced gout?
–Low dose aspirin can interfere with uric acid excretion
–Review antihypertensives
•Diuretics, beta-blockers, ACEI, non-losartan A2RA
increase sUA (losartan and calcium channel blockers
decrease sUA) excluding K sparing diuretics
how should you educate patients on GOUT?
treat as soon as attack occurs and continue
any established urate lowering therapy (ULT)
during an attack
•Rest affected joints, elevate and cool, ice-
packs
•Weight optimisation
•Diet optimisation
•Reduce alcohol intake
what management information should be given to patients?
Causes and consequences of gout •How to manage acute attacks •Aims and objectives of treatment •Lifestyle advice (diet, alcohol, obesity) •PIL available from ukgoutsociety.org
what is chronic gout management?
•Allopurinol 1st line
•Febuxostat 2nd line
•Benzbromarone 3rd line (specialist only)
•Co-prescribe prophylactic colchicine (500mcg
OD or BD) or low dose NSAID for up to 6m to
prevent acute flare
when should you not start chronic GOUT management?
Don’t START during an attack BUT CONTINUE if
already established on therapy and an attack
occurs
what is the aim of ULT?
is reduce and maintain serum uric
acid levels at or below a target level
–preventing further urate crystal formation and
–dissolves away existing crystals.
when should you start allopurinol?
Ensure at least 1-2 weeks from last attack when newly starting
what dose should you start allopurinol on?
50-100mg/day
what should you monitor when titrating up the allopurinol dose? what is the target dose?
Monitor sUA monthly and titrate up by 100mg to achieve
serum urate below target levels (<300umol/L)
what is the common allopurinol dose?
Commonly 300-600mg day (>300mg give in divided doses)
what should you not co-prescribe with allopurinol?
Do not co-prescribe with azathioprine (inhibits metabolism of
azathioprine- accumulation of toxic metabolites)
what are the most common s/e of allopironol?
rash and GI intolerance (take after
meals)
what is the starting dose of febuxostat?
Start low dose 80mg daily and increase in response to serum
urate (max 120mg/d)
what cautions should be taken into account with febuxostat?
liver impairment, thyroid disorders, IHD, heart
failure
what drugs should you avoid with febuxostat?
Avoid concomitant azathioprine/ mercaptopurine
when should you immediately stop febuxostat?
if hypersensitivity occurs (MHRA warning 2012) –Stevens-Johnson syndrome –Acute anaphylactoid/shock reactions –Discontinue and do not rechallenge
what are the less commonly used options initiated by specalists?
Uricosuric drugs (increase uric acid excretion)
–Benzbromarone (unlicensed, parallel import)
–Sulfinpyrazone
–Probenecid (unlicensed)
when should you have lifelong therapy?
unless you have a modifiable risk factor successfully addressed and clinical cure achieved
