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PHA223 > Gout in practice (Louise) > Flashcards

Gout in practice (Louise) Flashcards

1
Q

What is gout?

A 
a type of arthritis where crystals form inside and around joints
rapid onset (6-12hrs)
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2
Q

symptoms of gout

A

severe pain
swelling
warmth
tenderness in joint

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3
Q

Where is gout most commonly found?

A

1st metetarsophalangeal joint

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4
Q

areas of body you can find gout

A 
big toe
midfoot
ankle
knee
fingers
wrist
elbow
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5
Q

How many joints does gout affect usually?

A

monoarticular - affects one joint

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6
Q

What is tophus?

A

a build up of crystals at the surface of the joint

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7
Q

What is pseudo-gout?

A

non-urate crystal induced gout

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8
Q

septic arthritis

A

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

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9
Q

risk factors for gout

A 
sustained increase in serum urate (sUA)
age (O50)
male
renal impairment
hypertension
drugs (diuretics)
tophi
chronic arthritis
alcohol consumption
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10
Q

What is gold standard for diagnosos of gout?

A

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

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11
Q

When should gout be referred to secondary care?

A
  • 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
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12
Q

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

A

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

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13
Q

acute gout management

A
  • 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
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14
Q

NSAIDs that can be used

A

any at max dose
indometacin
diclofenac
naproxen

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15
Q

When to avoid NSAIDs

A

in HF
active GI ulcer
impaired renal function

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16
Q

colchicine dose

A

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

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17
Q

max dose of colchicine

A

500mcg QDS

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18
Q

Why is colchicine dose limited?

A

by diarrhoea and vomiting

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19
Q

When is colchicine most effective?

A

if taken within 12-24hrs of an attack

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20
Q

cautions with colchicine

A

narrow therapeutic window

very toxic in overdose

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21
Q

when to reduce dose/inc dosing interval of colchicine

A

in elderly

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22
Q

When is colchicine useful?

A

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

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23
Q

When to avoid colchicine in renal impairment?

A

eGFR < 10 (end stage)

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24
Q

max dose of colchicine per acute treatment course

A

max 6mg

don’t repeat within 3 days

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25
Q

colchicine interactions

A

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

26
Q

3rd line option

A

corticosteroids

-> can’t take NSAIDs and colchicine not tolerated

27
Q

How are steroids given for monoarthritis gout?

A

intra-articular injection
IM
oral

28
Q

What steroids are used?

A

methylprednisolone
hydrocortisone acetate
triamcinolone oral prednisolone

29
Q

oral prednisolone dose

A

20-40mg daily for 5 days

30
Q

steroids given by IM injection

A

methylprednisolone

triamcinolone

31
Q

lifestyle factors

A

reduce alcohol intake (especially purine rish - beer)

reduce purine rich foods (shellfish/meat)

32
Q

What risk should be reviewed annually?

A

CV risk

-> connection between sUA and CVD

33
Q

What drugs can induce gout?

A 
low dose aspirin (interferes with uric acid excretion)
antihypertensives
- DIURETICS
- beta blockers
- ACEI
- losartan/CCBs (dec sUA)
34
Q

What information to give to patients?

A
  • causes/consequences of gout
  • how to manage acute attacks
  • aims/objectives of treatment
  • lifestyle advice (diet, alcohol, obesity)
35
Q

When and what to review after acute attack?

A

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)
36
Q

When is ULT (urate lowering therapy) important?

A
  • 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
37
Q

When not to start chronic gout management?

A

during an attack

but continue if already established therapy and an attack occurs

38
Q

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

A

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

39
Q

co-prescribing for chronic gout management

A

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

40
Q

What is the aim of ULT (urate lowering therapy?

A

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

41
Q

When to start allopurinol?

A

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

42
Q

dose of allopurinol

A

low dose 50-100mg/day

43
Q

When to monitor sUA on allopurinol?

A

monthly

44
Q

How is allopurinol titrated?

A

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

45
Q

usual allopurinol dose

A

300-600mg daily

-> 300mg in divided doses

46
Q

When to adjust dose of allopurinol?

A

renal impairment

47
Q

What not to prescribe with allopurinol

A

azathioprine

-> inhibits metabolism of azathiporine, accumulation of toxic metabolites

48
Q

s/e of allopurinol

A 
rash
GI intolerance (take after meals)
49
Q

rash with allopurinol

A
  • if rash occurs stop and seek med advice
  • when rash resolved if it was mild, can gradually introduce again
  • but discontinue if rash returns
50
Q

When to start febuxostat?

A

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

51
Q

dose of febuxostat

A

low dose 80mg to start

increase in response to serum urate blood tests

52
Q

max dose of febuxostat

A

120mg daily

53
Q

cautions with febuxostat

A

liver impairment
thyroid disorders
IHD
HF

54
Q

what to avoid with febuxostat

A

azathioprine

mercaptopurine

55
Q

s/e with febuxostat

A

GI
abnormal LFT
oedema

56
Q

When should febuxostat be stopped immediately?

A

if hypersensitivity occurs

  • Stevens-Johnson syndrome
  • acute anaphylactoid shock/rxn
  • > discontinue and do not start again
57
Q

3rd line options for gout

A

drugs that increase uric acid excretion - uricosuric drugs

  • benzbromarone (unlicenced, parallel import)
  • sulfinpyrazone
  • probenecid (unlicenced)
58
Q

What is the target for sUA?

A

< 300 micro moles/L

59
Q

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

A

reduce ULT dose to maintain sUA at 300-360

60
Q

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

A

annually

PHA223 (43 decks)

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