Musculoskeletal: Gout

Question 1

Acute attacks of gout are usually managed how?

Answer 1

Acute attacks of gout are usually treated with high doses of NSAIDs such as diclofenac sodium, diclofenac potassium, etoricoxib, indometacin, ketoprofen, naproxen or sulindac.

Colchicine is an alternative in patients unable to take NSAIDs such as history of CVD issues.

Question 2

What is an alternative to high dose NSAIDs for the treatment of acute attacks of gout?

Answer 2

Colchicine is an alternative in patients in whom NSAIDs are contra-indicated. Aspirin is not indicated in gout.

Question 3

What medication should not be used to treat acute attacks of gout due to a risk of prolonging the attack indefinitely? (3)

Answer 3

Allopurinol, febuxostat, and uricosurics are not effective in treating an acute attack and may prolong it indefinitely if started during the acute episode.

Question 4

The use of colchicine to manage acute gout is limited by what?

Answer 4

The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.

Question 5

The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure for what reason?

Answer 5

The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.

Question 6

What treatment options are there for acute gout in those who cannot tolerate NSAIDs and in whom the use of colchicine has been ineffective?

Answer 6

Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate NSAIDs or who are resistant to other treatments. Intra-articular injection of a corticosteroid can be used in acute monoarticular gout [unlicensed indication]. A corticosteroid by intramuscular injection can be effective in podagra.

Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.

Question 7

What is Canakinumab?

Answer 7

Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.

Question 8

Canakinumab is a recombinant monoclonal antibody which can be used for the symptomatic treatment of frequent gouty arthritis attacks, which is defined as how many in the previous 3 months?

Answer 8

Canakinumab, a recombinant monoclonal antibody, can be used for the symptomatic treatment of frequent gouty arthritis attacks (at least 3 in the previous 12 months). It is licensed for use in patients whose condition has not responded adequately to treatment with NSAIDs or colchicine, or who are intolerant of them.

Question 9

For long-term control of gout the drugs allopurinol, febuxostat and sulfinpyrazone may be used. How do they work?

Answer 9

Both allopurinol and febuxostat reduce the formation of uric acid from purines as they are xanthine-oxidase inhibitors.

Sulfinpyrazone is an uricosuric drug which may be used to increase the excretion of uric acid in the urine.

Question 10

Allopurinol, febuxostat and sulfinpyrazone should never be started during an acute attack of gout, they are usually started how long after an attack has settled?

Answer 10

1-2 weeks.

Question 11

The initiation of long-term treatment for gout may precipitate an acute attack. How is this managed?

Answer 11

The initiation of treatment may precipitate an acute attack, and therefore an anti-inflammatory analgesic or colchicine should be used as a prophylactic and continued for at least one month after the hyperuricaemia has been corrected. However, if an acute attack develops during treatment, then the treatment should continue at the same dosage and the acute attack treated in its own right.

Question 12

Allopurinol is widely used and is especially useful in patients with renal impairment or urate stones when what drugs cannot be used?

Answer 12

Uricosuric drugs cannot be used.

Question 13

What side effect can allopurinol cause?

Answer 13

Rashes

Question 14

Febuxostat is licensed for the treatment of chronic hyperuricaemia where what has already occured?

Answer 14

Where urate deposition has already occured. It is not indicated for patients in whom the rate of urate formation is greatly increases such as in malignant disease or in Lesch-Nyhan syndrome.

Question 15

Can allopurinol and sulfinpyrazone be used in conjunction?

Answer 15

Yes:

Sulfinpyrazone can be used instead of allopurinol or in conjunction with it in cases that are resistant to treatment.

Question 16

What is a Specials uricosuric drug that can be used in patients with mild renal impairment?

Answer 16

Benzbromarone (available from ‘special-order’ manufacturers or specialist importing companies) is a uricosuric drug that can be used in patients with mild renal impairment.

Question 17

Why should increased fluid intake be encouraged in patients receiving treatment for gout?

Answer 17

Crystallisation of urate in the urine can occur with the uricosuric drugs and it is important to ensure an adequate urine output especially in the first few weeks of treatment. As an additional precaution the urine may be rendered alkaline.