Pharmaceutical Care of Gout

Question 1

What is the clinical presentation?

Answer 1

Hot, swollen joint, typically monoarticular

Question 1

What is the pathogenesis of gout?

Answer 1

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

Question 2

What are the risk factors?

Answer 2

Obesity + diet
Renal disease
Diabetes
Hypertension
High consumption of alcohol
Drugs - eg. diuretics

Question 3

When to suspect gout?

Answer 3

Rapid onset of severe pain with redness + swelling in metatarsophalangeal
OR tophi = long-term, untreated gout

Question 4

What is podagra?

Answer 4

Inflammation of big toe

Question 5

What are common sites?

Answer 5

Metatarsophalangeal (joint of 1st toe)
Midfoot, ankle, knee
Wrist
Finger joints
Elbow

Question 6

What tests should be done?

Answer 6

Measure serum urate level

Question 7

What level of urate confirms diagnosis?

Answer 7

360 micromol/L or more

Question 8

What age is it in?
Gout vs Pseudogout

Answer 8

> 40 years
Elderly

Question 9

What sites are affected?
Gout vs Pseudogout

Answer 9

Small joints - big toe
Large joints - knee

Question 10

What is the joint pain + swelling like?
Gout vs Pseudogout

Answer 10

Severe
Moderate

Question 11

What is the crystal deposited?
Gout vs Pseudogout

Answer 11

Uric acid
Calcium pyrophosphate

Question 12

What is the treatment?
Gout vs Pseudogout

Answer 12

Rest NSAIDs + Possibly allopurinol for prevention
Rest NSAIDS + joint aspiration

Question 13

What are the 3 phases of gout?

Answer 13

Long period of asymptomatic hyperuricaemia (1st attack)
Acute attacks of gouty arthritis (recurrent attacks)
Chronic tophaceous gout

Question 14

What are the non-pharmacological management of acute attacks?

Answer 14

Rest for 2-3 days
Ice

Question 15

What are the non-pharmacological management for prevention?

Answer 15

Hydration
Modification of diet + lifestyle

Question 16

Describe the non-pharmacological management of mild gout

Answer 16

Hydration
Avoid alcohol
Address obesity/manage diabetes + hypertension

Question 17

Why avoid alcohol?

Answer 17

Affects uric acid metabolism

Question 18

What does drinking water decrease?

Answer 18

Risk of effects of hyperuricaemia on kidneys, including stones

Question 19

What is gout an independent risk factor of?

Answer 19

CKD
MI
Cardiovascular disease mortality

Question 20

What is the acute treatment?

Answer 20

Colchicine/NSAIDs
Rest, ice, compression, elevation (RICE)
Steroid injections
IV uricase
Biologics

Question 21

What does IV uricase do?

Answer 21

Converts urate to allantoin, which is more soluble than uric acid in urine

Question 22

What is an example of a biologic?

Answer 22

Canakinumab

Question 23

What is Canakinumab licenced for?

Answer 23

Symptomatic treatment of frequent gouty arthritis attacks (at least 3 in last year)

Question 24

When is Canakinumab used?

Answer 24

Not responded adequately to treatment with NSAIDS/Colchicine

Question 25

What is 1st line treatment?

Answer 25

Offer NSAID, colchicine or short course of oral corticosteroid
PPI with NSAID?

Question 26

What happens if NSAID or colchicine unsuitable?

Answer 26

Consider intra-articular/intramuscular corticosteroid injection

Question 27

When is the only time you would offer an IL-inhibitor?

Answer 27

If NSAIDS, colchicine + corticosteroids are ineffective
BUT refer to rheumatology first

Question 28

What diet recommendations are recommended?

Answer 28

Reduce purine intake (reduced red meat, avoid liver, kidneys. shellfish + pulses)
Reduce fructose-containing drinks
Decrease alcohol consumption (especially beer)

Question 29

What weight loss is recommended?

Answer 29

1kg/month
Avoid crash diets/high protein diets

Question 30

What are colchicine safety issues?

Answer 30

Narrow therapeutic window

Question 31

Who is at risk with colchicine?

Answer 31

Renal, hepatic impairment
Extremes of age
GI/CV disease