Wk 16: Gout in practice

Question 1

What are the presentations of gout?

Answer 1

• Rapid onset (6-12hrs)
• Severe pain
• Swelling
• Redness
• Tenderness in joint
• 1st Metatarsophalangeal joint

Question 2

What are the symptoms for septic arthritis?

Answer 2

• Systemically unwell

- Painful ,hot, swollen joint

Question 3

What is the management for acute gout?

Answer 3

• Anti-inflammatory/analgesic straight away for 1-2 weeks (24-48h after attack resolved)
• Elevate + rest, keep cool + avoid trauma
• 1st line: NSAID full dose + PPI
• 2nd line: Colchicine
• 3rd line: Corticosteroid

Question 4

Which NSAIDs are recommended?

Answer 4

At max dose

• Indometacin
• Diclofenac
• Naproxen
• Avoid: HF, GI ulcer + impaired renal function

Question 5

Colchicine

Answer 5

• 500mcg 2-3x day until symptom relieved
• Max dose: 500mcg QDS
• Red/inc dose interval if elderly

Question 6

What is the max dose of colchicine per acute treatment course?

Answer 6

6mg don’t repeat w/in 3 days

Question 7

When do you give corticosteroid?

Answer 7

Can’t take NSAID + can’t tolerate colchicine

Question 8

Which corticosteroids are used?

Answer 8

• IA: Methylprednisolone

Oral pred: 20-40mg daily for 5 days

• IM: Methylpred

Question 9

What are the considerations for the management of acute gout?

Answer 9

Lifestyle:

• Red alcohol intake
• Red purine rich food (meat)

Treat CV risk factor + review annually

Drug induced gout

Question 10

What are drugs that induce gout?

Answer 10

• Low dose aspirin: interfere w/ uric acid excretion

- Hypertensives: diuretic, bblocker, ACE, non-losartan A2RA inc sUA

Question 11

When is ULT discussed?

Answer 11

Patients w/:

• 2+ attack in 12 months
• Tophaceous gout/ gouty erosions on X-ray
• Uric acid renal stones
• CKD + gout
• Diuretics + gout

Question 12

When do you start for the management of chronic gout?

Answer 12

Don’t start during attack, continue if established on therapy + attack occurs

Question 13

What is the management of chronic gout?

Answer 13

• 1st line: allopurinol
• 2nd line: Febuxostat
• 3rd line: Benzbromarone
• Co-prescribe prophylactic colchicine (500 mcg OD/BD) or low dose NSAID for 6m to prevent acute flare

Question 14

Allopurinol doses

Answer 14

• 1-2 wks from last attack
• Low dose 50-100mg/day
• Common: 300-600mg/day (>300mg divide dose)

Question 15

What do you not co-prescribe w/ allopurinol?

Answer 15

Azathioprine - inhibits metabolism of azathioprine - accumulates toxic metabolites

Question 16

What are the common s/e of allopurinol?

Answer 16

• GI intolerance (take after meal)

- Rash: stop + seek medical advice

Question 17

Febuxostat dose

Answer 17

• 1-2 wks from last attack
• Low dose 80mg daily + inc in response to serum urate
• Max 120mg/day

Question 18

What should be avoided when on febuxostat?

Answer 18

• Concomitant azathioprine

- Mercaptopurine

Question 19

What are the s/e of febuxostat?

Answer 19

• GI
• Anormal LFT
• Oedema

Question 20

When should you stop taking febuxostat?

Answer 20

Hypersensitivity occurs:

• Stevens-Johnson syndrome
• Acute Anaphylactic/shock reactions