Gout in practice (Louise)

Question 1

What is gout?

Answer 1

a type of arthritis where crystals form inside and around joints
rapid onset (6-12hrs)

Question 2

symptoms of gout

Answer 2

severe pain
swelling
warmth
tenderness in joint

Question 3

Where is gout most commonly found?

Answer 3

1st metetarsophalangeal joint

Question 4

areas of body you can find gout

Answer 4

big toe
midfoot
ankle
knee
fingers
wrist
elbow

Question 5

How many joints does gout affect usually?

Answer 5

monoarticular - affects one joint

Question 6

What is tophus?

Answer 6

a build up of crystals at the surface of the joint

Question 7

What is pseudo-gout?

Answer 7

non-urate crystal induced gout

Question 8

septic arthritis

Answer 8

if systemically unwell and painful, hot, swollen joint
refer immediately for emergency joint aspiration and culture
can be fatal if recognised late

Question 9

risk factors for gout

Answer 9

sustained increase in serum urate (sUA)
age (O50)
male
renal impairment
hypertension
drugs (diuretics)
tophi
chronic arthritis
alcohol consumption

Question 10

What is gold standard for diagnosos of gout?

Answer 10

urate crystals in fluid aspirated from joint (in secondary care)

Question 11

When should gout be referred to secondary care?

Answer 11

• septic arthritis suspected (urgently)
• unresponsive to uric acid lowering or persistent symptoms after max NSAIDs
• complications relating to gout (neuropathy)
• persists despite uric acid levels being lowered
• young onset (<30yrs)
• pregnancy
• diagnostic uncertainty

Question 12

acute gout management 1st/2nd/3rd line

Answer 12

1st line - NSAID full dose (or COX-2 inhibitor) AND PPI
2nd line - colchicine
3rd line - corticosteroids

Question 13

acute gout management

Answer 13

• start antiinflammatory/analgesic straight away and continue for 1-2 weeks (24-48hrs after the attack has resolved)
• elevate joint/rest/keep cool/avoid trauma to joint

Question 14

NSAIDs that can be used

Answer 14

any at max dose
indometacin
diclofenac
naproxen

Question 15

When to avoid NSAIDs

Answer 15

in HF
active GI ulcer
impaired renal function

Question 16

colchicine dose

Answer 16

500mcg 2-3 times a day until symptoms relieved or until diarrhoea/vomiting occurs

Question 17

max dose of colchicine

Answer 17

500mcg QDS

Question 18

Why is colchicine dose limited?

Answer 18

by diarrhoea and vomiting

Question 19

When is colchicine most effective?

Answer 19

if taken within 12-24hrs of an attack

Question 20

cautions with colchicine

Answer 20

narrow therapeutic window

very toxic in overdose

Question 21

when to reduce dose/inc dosing interval of colchicine

Answer 21

in elderly

Question 22

When is colchicine useful?

Answer 22

warfarin - can’t take NSAIDs and warfarin together
renal impairment - can’t give NSAIDs, adjust dose (caution)
HF - can’t take NSAID

Question 23

When to avoid colchicine in renal impairment?

Answer 23

eGFR < 10 (end stage)

Question 24

max dose of colchicine per acute treatment course

Answer 24

max 6mg

don’t repeat within 3 days

Question 25

colchicine interactions

Answer 25

caution/low dose with CYP450 3A4 inhibitors (clarithromycin, erythromycin) caution in renal impairment and statins - report myopathy and rhabdomylosis

Question 26

3rd line option

Answer 26

corticosteroids | -> can't take NSAIDs and colchicine not tolerated

Question 27

How are steroids given for monoarthritis gout?

Answer 27

intra-articular injection IM oral

Question 28

What steroids are used?

Answer 28

methylprednisolone hydrocortisone acetate triamcinolone oral prednisolone

Question 29

oral prednisolone dose

Answer 29

20-40mg daily for 5 days

Question 30

steroids given by IM injection

Answer 30

methylprednisolone | triamcinolone

Question 31

lifestyle factors

Answer 31

reduce alcohol intake (especially purine rish - beer) | reduce purine rich foods (shellfish/meat)

Question 32

What risk should be reviewed annually?

Answer 32

CV risk | -> connection between sUA and CVD

Question 33

What drugs can induce gout?

Answer 33

``` low dose aspirin (interferes with uric acid excretion) antihypertensives - DIURETICS - beta blockers - ACEI - losartan/CCBs (dec sUA) ```

Question 34

What information to give to patients?

Answer 34

- causes/consequences of gout - how to manage acute attacks - aims/objectives of treatment - lifestyle advice (diet, alcohol, obesity)

Question 35

When and what to review after acute attack?

Answer 35

review 4-6 weeks after - check sUA and renal function - check lifestyle factors - assess CV risk factors (and treat) - review prescribed meds (diuretics) - discuss urate lowering therapy (ULT)

Question 36

When is ULT (urate lowering therapy) important?

Answer 36

- 2+ attacks in 12mths - tophaceous gout/gouty erosions on x-ray (tophi) - uric acid renal stones (kidney stones) - CKD and gout - continuing diuretics (HF) and gout

Question 37

When not to start chronic gout management?

Answer 37

during an attack | but continue if already established therapy and an attack occurs

Question 38

management of chronic gout 1st/2nd/3rd line

Answer 38

1st line - allopurinol 2nd line - febuxostat 3rd line - benzbromarone (specialist only)

Question 39

co-prescribing for chronic gout management

Answer 39

low dose colchicine 500mg OD/BD OR low dose NSAID -> up to 6 months to prevent acute flare

Question 40

What is the aim of ULT (urate lowering therapy?

Answer 40

reduce and maintain serum uric acid leves at or below target level prevent further urate crystal formation dissolve existing crystals

Question 41

When to start allopurinol?

Answer 41

at least 1-2 weeks from last attack when newly starting

Question 42

dose of allopurinol

Answer 42

low dose 50-100mg/day

Question 43

When to monitor sUA on allopurinol?

Answer 43

monthly

Question 44

How is allopurinol titrated?

Answer 44

titrate up by 100mg to achive serum urate below target levels (<300micro moles/L)

Question 45

usual allopurinol dose

Answer 45

300-600mg daily | -> 300mg in divided doses

Question 46

When to adjust dose of allopurinol?

Answer 46

renal impairment

Question 47

What not to prescribe with allopurinol

Answer 47

azathioprine | -> inhibits metabolism of azathiporine, accumulation of toxic metabolites

Question 48

s/e of allopurinol

Answer 48

``` rash GI intolerance (take after meals) ```

Question 49

rash with allopurinol

Answer 49

- if rash occurs stop and seek med advice - when rash resolved if it was mild, can gradually introduce again - but discontinue if rash returns

Question 50

When to start febuxostat?

Answer 50

at least 1-2 weeks from last attack when nwely starting

Question 51

dose of febuxostat

Answer 51

low dose 80mg to start | increase in response to serum urate blood tests

Question 52

max dose of febuxostat

Answer 52

120mg daily

Question 53

cautions with febuxostat

Answer 53

liver impairment thyroid disorders IHD HF

Question 54

what to avoid with febuxostat

Answer 54

azathioprine | mercaptopurine

Question 55

s/e with febuxostat

Answer 55

GI abnormal LFT oedema

Question 56

When should febuxostat be stopped immediately?

Answer 56

if hypersensitivity occurs - Stevens-Johnson syndrome - acute anaphylactoid shock/rxn - > discontinue and do not start again

Question 57

3rd line options for gout

Answer 57

drugs that increase uric acid excretion - uricosuric drugs - benzbromarone (unlicenced, parallel import) - sulfinpyrazone - probenecid (unlicenced)

Question 58

What is the target for sUA?

Answer 58

< 300 micro moles/L

Question 59

What is the dose for when sUA is at target/no tophu/attacks stopped?

Answer 59

reduce ULT dose to maintain sUA at 300-360

Question 60

How often should ULT be measured when target sUA reached/no tophi/no attacks?

Answer 60

annually