Hyperuricaemia and gout Flashcards
What is the pharmacological treatment for an acute gout attack?
From what age are these suitable for
Acute attacks should be treated as early as possible (as soon as an attack occur)
16 years and above
- NSAIDs max dose as early as possible and continue 1-2 days after attack has resolved.
Need to co-prescribe PPI for gastric protection,
- Oral Colchicine
Is Aspirin suitable for treatment of gout?
No. Aspirin is not indicated for gout
When is colchicine used instead of an NSAID?
In patients where NSAIDs are contra-indicated.
such as heart failure patients as it does not induce fluid retention like NSAIDs do.
Also can be given to pts receiving ANTICOAGULANTS
What is the option for a patient when NSAID or colchicine are not tolerated?
A short course of oral corticosteroids or a single intramuscular corticosteroid injection
If a patient is already on the long term prophylaxis for gout and then they have an attack, should allopurinol or febuxostat be stopped?
Do not stop them if pt is already established on them
Can allopurinol or febuxostat be started whilst a patient has an active attack?
No. They can exacerbate and prolong the attack.
What is Canakinumab and when can it be used in the treatment of gout?
Recombinant monoclonal antibody
can be used for the symptomatic treatment of frequent gouty arthritis attack.
Licensed for those that haven’t responded to NSAIDs or colchicine or who are intolerant of them.
What follow up is recommended after an acute attack of gout?
- Follow up 4-6 weeks after attack
- Serum uric acid level
- Blood pressure, HbA1c, renal function & lipid profile.
- Use of ULT (Urate-lowering therapy)
In a person with heart failure, continuing on diuretics and is using NSAID for pain relief. What should be monitored?
Renal Function
When should you refer? (4)
- Gout occurs during pregnancy or in young person (under 30)
- Persistent symptoms during an acute attack despite max dose of NSAID
- Requires ULT but they are not tolerated or contraindicated
- Max dose ULT and still having attacks
When should the use of ULT be advised?
- Two or more attacks in 12 months
- Joint damage
- Renal impairment (eGFR less than 60ml/min)
- History of urinary stones
- Diuretic use
What is 1st line ULT?
When is it usually started?
ALLOPURINOL
(xanthine-oxidase inhibitor)
1-2 weeks after an attack has settled.
Start at a low dose and titrate upwards (where tolerated) every four weeks until the serum uric acid (SUA) level is below 300 micromol/L.
Starting a ULT can precipitate an acute attack. What can the patient take as a prophylactic?
low dose NSAID or colchicine & for at least one month after the hyperuricaemia has been corrected.
Colchicine preferred.
What is second line ULT?
What needs to be checked before treatment initiation.
Febuxostat as an alternative second-line therapy if allopurinol is not tolerated or is contraindicated
Check liver function tests prior to initiation.
Start at a low dose and increase after 4 weeks if SUA level is above 300 micromol/L.
Can urate-lowering treatment be reduced or stopped in chronic gout?
Once allopurinol or febuxostat is started, treatment is usually lifelong.
After some years of treatment, once serum uric acid target is reached and clinical ‘cure’ has been achieved (acute attacks have stopped and tophi have resolved), consider reducing the dose of ULT to maintain the serum uric acid level between 300-360 micromol/L.
Monitoring required for ULT?
- serum uric acid (SUA) level
- renal function
every 4 weeks
until SUA is in target range, then annually thereafter, and aim for a SUA level below 300 micromol/L
Dose of colchicine (plant alkaloid) for
- acute gout
- short term prohylaxis during initial ULT
Acute gout
500micrograms 2-4 times a day until symptoms relieved
Max 6mg per course. Do NOT repeat course within 3 days.
Short term:
500micrograms BD
If a patient is on one of the following what should happen to the dose of cochicine?
- Moderate inhibitors of CYP34A
- Potent inhibitors of CYP34A or p-glycoprotein
- Pts with hepatic or renal impairment and taking potent CYP34A inhibitors
- Reduce dose by half when taking moderate inhibitors
- Reduce by 75% (to 1/4 of dose) if taking potent
- Avoid use
Name some examples of P-glycoprotein inhibitors?
3 groups
- Amiodarone
- Clarithromycin/ Erythromycin, Azithromycin
- Itraconazole / Ketoconazole
Colchicine should be used with caution in?
- Cardiac disease
- Elderly
- GI disease
What criteria shows that a colchicine Rx is potentially inappropriate for the elderly?
STOPP criteria
- if eGFR less than 10ml/min/1.73m2 (risk of toxicity)
2. for chronic treatment of gout where there is no contraindication to a xanthine-oxidase inhibitor
Can colchicine be used in the following:
- Pregnancy
- Breastfeeding
- Hepatic impairment
- Renal impairment
- Avoid in pregnancy - teratogenicity
- Present in milk. Advise caution
- Caution in mild & moderate hepatic but avoid in severe
- Avoid if eGFR less than 10
Reduce dose or increase dose interval if eGFR 10-50
Side effects of Colchicine?
Common
Others - weird ones?
- Abdo pain, diarrhoea, nausea, vomiting
- BLOOD DISORDERS/ HORMONES?
Agranulocytosis, GI haemorrhage, menstrual cycle irregularities, sperm abnormalities, thrombocytopenia
Dose of allopurinol for prophylaxis of gout and of uric acid and calcium oxalate renal stones?
- Normal
- Mild conditions
- Moderate Severe
- Severe
- Initially 100mg daily - adjust based on uric acid level
- 100-200mg daily - preferably after food
- 300-600mg daily in divided doses (max per dose 300mg) - after food
- 700-900mg daily (max 300mg per dose) - after food
Common side effect of allopurinol?
- RASH (discontinue, if mild re-introduce cautiously but discontinue immediately if reoccurs.
Can allopurinol be used in the following:
- Pregnancy
- Breastfeeding
- Hepatic impairment
- Renal impairment
- Ok if no other safer alternative
- Present in milk - not known to be harmful
- Monitor liver function during early stages of treatment. Reduce dose if required
- Max 100mg daily, increase only if response inadequate.
In severe - reduce below 100mg daily
What 3 advisory labels go with allopurinol tablets?
- Do not stop taking this medicine unless Dr tells u
- Take with or after food
- Take with a full glass of water
What is the dose for Febuxostat for chronic gout?
Initially 80mg OD
if after 2-4 weeks and serum uric acid greater 6mg/100ml then increase to 120mg OD
MHRA warning for Febuxostat? (2)
- June 2012 - serious hypersensitivity reactions, inc. stevens-johnson syndrome and acute anaphylactic shock.
Must be stopped immediately if these occur. Most cases occur in 1st month. History of hypersensitivity with allopurinol & or renal disease may indicate potential hypersensitivity to febuxostat.
- July 2019 - Increased risk of cardiovascular death & death in patients with history of major cardiovascular disease
Avoid use in those with major cardiovascular disease such as myocardial infarction, stroke or unstable angina
Only use if allopurinol is not tolerated or contra-indicated.
Febuxostat used in caution with which patients? (5)
- Congestive heart failure
- Ischaemic heart disease
- Major cardiovascular disease
- Thyroid disorders
- Transplant recipients
When starting allopurinol or febuxostat - what else should be started with them as prophylaxis?
Allo - NSAID or colchicine for first 3 months
Febux - NSAID or colchicine for first 6 months
