Module 3: Gout Treatement Flashcards
What is gout?
A form of inflammatory arthritis when urate crystals accumulate in your joint (from high uric acid in your blood), causing the inflammation and intense pain of a gout attack. Uric acid is a byproduct of the breakdown of purines in the body.
Can effect any joint but typically big toe, ankles, knees, elbows, wrists and fingers.
How is gout diagnosed?
Symptoms:
- painful join inflammation, often in the big toe
- swelling or tenderness in a joint or bursa
Lab tests:
- blood test = high uric acid levels
- joint fluid test = urate crystal presence
- urine test = high levels of uric acid
Imaging:
- x-ray (r/o other causes)
- US: detect crystals
- CT or DECT
What are indications for pharmacotherapy?
Diagnosis of gout confirmed - treat immediately.
What is septic arthritis?
Infected joint. Do not treat as gout.
What is first line pharmacotherapy for gout flare?
Antiinflammatory therapy:
Systemic glucocorticoid
NSAID
Colchicine
When is allopurinol indicated for gout?
Long term treatment and prevention of gout in patients with high urate levels.
What is the efficacy of the different antiinflammatory treatments?
Glucocorticoids are as efficacious as NSAIDs and may be associated with fewer serious adverse outcomes.
Colchicine may carry a slightly higher risk of drug-related adverse effects.
What are contraindications to systemic glucocorticoids?
Avoid in concurrent infection, brittle diabetes, recent sx with unhealed wound, hx of allergy or intolerance.
What is the dose and duration of oral glucocorticoid therapy?
Prednisone 40mg daily until flare resolves then taper. May range from a few days to weeks.
Prompt treatment typical need is 5-10 days
Severe or delayed treatment = several weeks
Hx of relapsing or refractory disease = taper extended to 14-21 days
What are contraindications to intraarticular glucocorticoids?
Septic arthritis
Patients on anticoagulants
What is the efficacy of intraarticluar glucocortiocoids?
single injection provides relief within 24 hours.
What are contraindications to NSAIDs?
Kidney disease
hyperkalemia
duodenal or gastric ulcer
HTN
mod to severe uncompensated HF
cirrhosis
Which NSAID and what dose and duration is recommended?
Naproxen 500mg BID
Co-administration of PPI in pts at risk of gastropathy
Duration:
- for those starting allopurinol, tx with low dose NSAID can extend 3-6 months to prevent flares
What is the efficacy of NSAIDs?
Pain relief within 3-7 days.
When is colchicine contraindicated?
Any kidney or hepatic impairment
Recent or current P-glycoprotein inhibitor or an agent that strongly reduces CYP3A4
Watch for drug interactions.
What is the dose and duration for colchicine?
Initial: 1-1.2 mg followed in 1 hour by another 0.5-0.6mg for a total first day dose of 1.5-1.8mg
Subsequently reduced to 0.5mg-0.6mg BID until 48 hours after resolution
Other than antiinflammatory therapy, what 2 things are considered for a gout flare up?
- consider urate lowering agents or continue if already taking (e.g. allopurinol)
- supportive measures such as ice packs, splints/braces to immobilize and reduce pain
Patients on anticoagulants should consider which pharmacologic treatment?
Colchicine or systemic glucocorticoids
Older adults should consider which pharmacologic tx?
Systemic or intraarticular glucocorticoids
Patients in end stage kidney disease and transplantation should consider which pharmacologic tx?
systemic or intraarticular glucocortiocoids
What is the drug formulary for each of these therapies?
Prednisone - Partial coverage
Naproxen - Partial coverage
Colchicine - Partial coverage
What are pregnancy and lactation considerations in tx of gout?
Pregnancy - systemic glucocorticoids. Alternative is colchicine up to 20 weeks gestation.
Lactation - use glucocorticoids or NSAIDs. Avoid colchicine.
