Gout In Practice

Question 1

How can we recognise gout?

Answer 1

-rapid onset(6-12hrs)
-redness and warmth
-swelling
-pain in the joints
-most commonly found mid foot, ankle, knee, fingers, wrist and elbows

Question 2

What is septic arthritis?

Answer 2

If the patient is systemically unwell and painful,hot, swollen joints present, these patients should be sent for an immediate emergency joint aspiration and culture.

IF THIS IS RECOGNISED TOO LATE IT COULD BE FATAL TO THE PATIENT.

Question 3

What risk factors are associated with gout?

Answer 3

• sustained increased serum urate levels
  -age, more prevalent in older patients
  -male
  -renal impairement
  -hypertension
  -drugs like diuretic use
  -Tophi
  -chronic Arthritis
  -too much alcohol

Question 4

How do we treat ACUTE gout?

Answer 4

1st LINE - (NSAIDs or COX-2 inhibitor) with a PPI
2nd LINE- Colchicine (can only take for a few days)
3rd LINE- corticosteroids

If there is a poor response try to combine the following
-suggest not to give an NSAID with colchicine as they both pose the effect of GI disturbances.

Question 5

What NSAIDs can we use in the treatment for gout?

Answer 5

1.indometacin
2.diclofenac
3.naproxen

Question 6

Which patients do we avoid using NSAIDs in?

Answer 6

-avoid heart failure patients
-active GI ulcers
-impaired renal function
-patients taking methotrexate, this is because NSAIDs can increase the toxicity of methotrexate.
-patients on warfarin

Question 7

How to advice a patient on taking colchicine ?

Answer 7

• it is more effective to take this medication within 12-24hrs of an attack.
  -max dose is 500mcg four times a day but normally dropped down to 2-3 times daily due to effects of diarrhoea and toxicity.
  -Max 6mg, do not repeat within 3 days

Question 8

Who can we prescribe colchicine?

Answer 8

-can give to patients cautiously in renal impairment, the dose will need adjusting.
AVOID IN PATIENTS WHOS eGFR IS <10

-useful to use if on warfarin as the patient cannot take NSAIDs if using warfarin, increased risk of GI bleed.

Question 9

What drugs does colchicine interact with?

Answer 9

• clarithromycin
  -erythromycin
  -tolbutamide
  -fluoxetine

Careful in patients with renal impairment and using statins, can cause myopathy which is muscle weakness.

Question 10

When do we give corticosteroids and what examples are used in the treatment of gout?

Answer 10

Corticosteroids are last line, if NSAIDs and colchicine are not tolerated or do not seem to pose any effect.

Oral corticosteroids:
-prednisolone (20-40mg) for 5 days =short course

Intra articulation injections:
-methylprednisolone
-hydrocortisone acetate
-triamcinolone oral prednisolone

IM injections:
-methylprednisolone
-triamcinolone

Question 11

How else may we manage a patient with acute gout?

Answer 11

Assess lifestyle:
-ensure the patient is cutting down on purine rich foods
-reduce alcohol intake

Treat CVD risk factors:
-review annually
-there is a link seen between SUA (serum uric acid) and CV disease.

Consider the patients drugs:
-if the patient is on low dose aspirin, this can be stopped as it interferes with he uric acid excretion.

review the antihypertensives:
-diuretic (can reduce doses)
-beta blockers
- ace inhibitors
COLCHICINE AND STATINS CAN INTERACT, SO START STATINS LATER IF NEEDED.

Question 12

WHAT information do we give patients in regards to gout?

Answer 12

GIVE THE PATIENTS VERBAL AND WRITTEN ADVICE ON:
-The causes of gout
-if not treated what the consequences would be
-aims and objectives of the treatments used
-lifestyle advice, which foods and drinks that they should avoid

Question 13

What tests are required post attack?

Answer 13

REVIEW 4-6 POST ATTACK

-check serum uric acid levels
-renal function tests
-check lifestyle
-assess the patients CV risk (to treat underlying risk factors)
-review prescribed medication such as diuretics

CHECK URATE LOWERING THERAPY:
-this is important especially with patients:
-2 or more attacks in the past 12 months
-uric acid renal stones
-CKD
-continuing diuretics
-tophaceous gout

Question 14

How do we manage chronic gout?

Answer 14

DONT START THESE MENTIONED MEDICATIONS DURING THE ATTACK AS CAN MAKE THE GOUT WORSE- SUGGEST TO START 1-2 WEEKS POST ATTACK.

1st line- Allopurinol
2nd line - FEBUXOSTAT
3rd line- Benzbromarone (specialist only )

In addition prescribe Colchicine 500mcg once or twice daily or low dose NSAID for up to 6 months to prevent acute flares

Question 15

What is the overall aim of the urate lowering therapy?

Answer 15

1. Prevent further urate crystal formation in the joints
   2.dissolve away any existing crystals

Question 16

When a patient is administrating allopurinol what monitoring do we carry out?

Answer 16

-starts low dose 50-100mg per day
-Monitor serum urate acid levels and titration should be increased by 100mg to achieve serum urate below target levels.
-dose adjustments are mandatory in regally impaired patients

Question 17

What are the most common side effects of allopurinol?

Answer 17

-rash, if it occurs stop medication and seek medical attention.
If the rash goes away, slowly introduce the med back if the rash reappears discontinue.
-GI disturbances, thus it is suggested to take after meals.

Question 18

What drug do we not co prescribe with allopurinol?

Answer 18

AZATHIOPRINE
This is because allopurinol inhibits the metabolism of azathioprine, thus resulting in an accumulation of toxic metabolites.

Question 19

What advice do we normally give to patients on FEBUXOSTAT?

Answer 19

-start 1-2 weeks post attack
-start at a low dose of 80mg daily, and slowly increase to a max of 120mg per day.
-avoid azathioprine and mercaptopurine

Question 20

Which patients do we be careful with when prescribing FEBUXOSTAT?

Answer 20

-liver impairement
-thyroid disorders
-heart failure

Question 21

What are the most common side effects of FEBUXOSTAT?

Answer 21

-GI disturbances
-abnormal LFT
-oedema

STOP IMMEDIATELY IF A RASH OCCURS, FACE SWELLING AND CANNOT BREATHE.

Discontinue if the above occurs and do not restart.

Question 22

Give examples of uricosuric drugs and explain what the mechanism of action is?

Answer 22

1.benzbromarone
2.sulfinpyrazone
3.probenecid

Works by increasing the uric acid excretion via the kidneys.

Question 23

What targets should we be reaching for patients on gout therapies?

Answer 23

-<300umol/L =clinical cure
-consider reducing ULT dose to maintain sUA 300-360
-check ULT annually to ensure the target is maintained
-continue lifelong treatment unless modifiable risk factors are successfully addressed and a clinical cure is achieved.