Hyperuricaemia and gout

Question 1

Drug causes of gout:

Answer 1

Diuretics, Ciclosporin, Tacrolimus, Cytotoxic, Cancer

Question 2

Treatment in acute attacks of gout..

Answer 2

usually a high dose NSAID (e.g. Diclofenac, Etoricoxib, Indometacin, Ketoprofen, Naproxen or Sulindac) OR Colchicine is given if NSAIDs are contra-indicated (e.g. in severe HF).

Question 3

Colchicine

Answer 3

• Colchicine is not frequently prescribed as it’s more toxic than NSAID’s.
• It does not cause fluid retention and can be safely given in heart failure and with anticoagulants.
• Colchicine may be more appropriate in patients with peptic ulceration and hypertension.
• Colchicine should be avoided in pregnancy and it may be affected by enzyme inhibitors or inducers.
• Reduce dose by half with concurrent use of moderate CYP3A4 inhibitors or reduce dose by 75% if potent CYP3A4 inhibitors or P-glycoprotein inhibitors. Avoid concurrent use in hepatic or renal impairment.

Question 4

Allopurinol:

Answer 4

• Starting allopurinol treatment can precipitate an acute attack, so prophylactic analgesia and anti-inflammatories are given. Start allopurinol 1-2 weeks after acute attack has been corrected.
• Renal impairment increases the chances of developing gout. Allopurinol may also be used to prevent hyperuricemia linked with cytotoxic drugs.
• Continue NSAID/Colchicine for at least ONE month (6 months with febuoxostat) as initiation of long-term treatment may precipitate acute attack

Question 5

Allopurinol should only be started if …

Answer 5

• acute attacks are common or tophi are present (‘stones’). Also, if patients who are controlled with allopurinol experience an acute attack, the allopurinol should continue and not be stopped. Allopurinol should be withdrawn if the patient develops a rash.

Question 6

allopurinol toxicity with other drugs…

Answer 6

• Reduce dose of mercaptopurine/azathioprine by ¼ to ½ with allopurinol due to toxicity

Question 7

Allopurinol should be taken …

Answer 7

• after food and taken with a full glass of water. The dose is adjusted based on the blood results and should NOT be stopped under normal circumstances.