Pharmaceutical Care of Gout Flashcards
What is the clinical presentation?
Hot, swollen joint, typically monoarticular
What is the pathogenesis of gout?
High urate intake or reduced urate excretion
= urate crystals in cool peripheries
THEN mechanical trigger/infection
= crystals exposed - intensely proinflamed
= TNFalpha, IL-6, IL-1
= GOUT
What are the risk factors?
Obesity + diet
Renal disease
Diabetes
Hypertension
High consumption of alcohol
Drugs - eg. diuretics
When to suspect gout?
Rapid onset of severe pain with redness + swelling in metatarsophalangeal
OR tophi = long-term, untreated gout
What is podagra?
Inflammation of big toe
What are common sites?
Metatarsophalangeal (joint of 1st toe)
Midfoot, ankle, knee
Wrist
Finger joints
Elbow
What tests should be done?
Measure serum urate level
What level of urate confirms diagnosis?
360 micromol/L or more
What age is it in?
Gout vs Pseudogout
> 40 years
Elderly
What sites are affected?
Gout vs Pseudogout
Small joints - big toe
Large joints - knee
What is the joint pain + swelling like?
Gout vs Pseudogout
Severe
Moderate
What is the crystal deposited?
Gout vs Pseudogout
Uric acid
Calcium pyrophosphate
What is the treatment?
Gout vs Pseudogout
Rest NSAIDs + Possibly allopurinol for prevention
Rest NSAIDS + joint aspiration
What are the 3 phases of gout?
Long period of asymptomatic hyperuricaemia (1st attack)
Acute attacks of gouty arthritis (recurrent attacks)
Chronic tophaceous gout
What are the non-pharmacological management of acute attacks?
Rest for 2-3 days
Ice
What are the non-pharmacological management for prevention?
Hydration
Modification of diet + lifestyle
Describe the non-pharmacological management of mild gout
Hydration
Avoid alcohol
Address obesity/manage diabetes + hypertension
Why avoid alcohol?
Affects uric acid metabolism
What does drinking water decrease?
Risk of effects of hyperuricaemia on kidneys, including stones
What is gout an independent risk factor of?
CKD
MI
Cardiovascular disease mortality
What is the acute treatment?
Colchicine/NSAIDs
Rest, ice, compression, elevation (RICE)
Steroid injections
IV uricase
Biologics
What does IV uricase do?
Converts urate to allantoin, which is more soluble than uric acid in urine
What is an example of a biologic?
Canakinumab
What is Canakinumab licenced for?
Symptomatic treatment of frequent gouty arthritis attacks (at least 3 in last year)
When is Canakinumab used?
Not responded adequately to treatment with NSAIDS/Colchicine
What is 1st line treatment?
Offer NSAID, colchicine or short course of oral corticosteroid
PPI with NSAID?
What happens if NSAID or colchicine unsuitable?
Consider intra-articular/intramuscular corticosteroid injection
When is the only time you would offer an IL-inhibitor?
If NSAIDS, colchicine + corticosteroids are ineffective
BUT refer to rheumatology first
What diet recommendations are recommended?
Reduce purine intake (reduced red meat, avoid liver, kidneys. shellfish + pulses)
Reduce fructose-containing drinks
Decrease alcohol consumption (especially beer)
What weight loss is recommended?
1kg/month
Avoid crash diets/high protein diets
What are colchicine safety issues?
Narrow therapeutic window
Who is at risk with colchicine?
Renal, hepatic impairment
Extremes of age
GI/CV disease
