In the Clinic - Gout

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In the Clinic -Gout

• Team Meeting Presentations

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Risk Factors for Gout

• Hyperuricemia
• Male sex if lt60
• Obesity
• High purine diet (red meat shellfish)
• Alcohol (esp beer and spirits) and high fructose
  drinks
• Medications (thiazides cyclosporine)
• CKD
• Lead exposure
• Organ transplantation
• Specific diseases (htn, DM, hyperlipidemia,
  hematologic malignancies genetics

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Are there effective strategies for primary
prevention of gout?

• Dietary modifications, weight loss
• Pharmacologic therapy is not recommended when
  hyperuricemia is assymptomatic
• Pharmocologic therapy is recommended in pts on
  chemo for hematologic malignancies
• Uric acid lowering drugs and hydration prevent
  secondary gout due to tumor lysis
• Without this treatment, uric acid nephropathy
  with tubular obstruction can develop

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Is gout associated with increased risk for CV
disease and can this be prevented?

• Both CV disease and gout are associated with
  serum markers of inflammation
• CV disease risk is increased in persons with gout
  or hyperuricemia
• Opinions differ on whether the association of an
  elevated serum urate level with increased CV
  disease is modifiable

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What symptoms and physical findings suggest gout?

• Warmth, swelling, redness and severe joint pain
• Of first attacks, 90 are monoarticular
• Common sites of crystal deposition, tophus
  development helix of the ear, lower extremities
• Other sites periarticular structures (bursae,
  tendons)
• Crystals are more likely in previously diseased
  joints
• Other forms of arthritis increase gout risk

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Symptoms and Findings

• Episodic self-limited joint pain, swelling,
  erythema
• Attacks often occur at night or in early morning
• Trauma may trigger release of crystals into joint
  space
• Attacks often subside in 3-14 days without
  treatment

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Tests to Diagnose Gout

• Serum urate level- may be normal in acute flare
• CBC with differential
• Synovial fluid or tophus aspirate examination
• Polarizing scope, cell count culture
• Radiography to r/o other causes or for findings
  suggestive of chronic gout

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Podagra
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Uric Acid Crystals
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Radiograph chronic gout
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Value of radiography in the diagnosis of gout

• Early in course- to r/o other conditions
• Later in course can show prominent,
  proliferative bony reaction
• Gout related tophi cause bone destruction away
  from the joint
• Gout less likely to cause joint space narrowing
  than psoriatic arthritis or rheumatoid arthritis

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Differential Diagnosis of Gout

• Rheumatoid arthritis
• Symmetrical polyarthritis in small joints of
  hands and feet
• Hand involvement more likely than in gout
• Subcutaneous nodules in 20
• XRAY soft tissue swelling diffuse joint space
  narrowing, marginal erosions of small joints,
  osteopenia

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Differential Diagnosis of Gout

• Pseudogout calcium pyrophosphate deposition
  disease
• Appears in unusual places - elbows, wrists
  without trauma
• Affects 10-15 gt65
• XRAY looks like RA or osteoarthritis but with
  bony repair
• Cartilage calcification
• Triangular cartilage - pathognomonic

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Differential Dx of Gout contd

• Septic Arthritis
• Fever, arthritis, great tenderness
• Up to ½ have concomitant RA
• Source is often evident
• Diagnose and treat immediately to avoid joint
  destruction

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Differential Diagnosis Gout- Contd

• Cellulitis gout often mistaken for cellulitis
  also
• Erythema, swelling of the extremity, very tender,
  febrile
• Often previous surgery or infection at the site
• Xray soft tissue swelling
• Staph/strep most likely

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Differential Dx- Gout Contd

• Osteoarthritis bony enlargement without signif
  inflammation usually May often involve the
  halus valgus as in gout
• Psoriatic arthritis DIPs often, nail changes
  XRAY central erosions, subchondral sclerosis,
  bony repair signsuric acid levels might be high
  due to proliferative skin changes
• Sarcoidosis acute disease can involve ankles
  look for subcut nodules, erythema nodosum
• Assoc parotits, uveitis, hilar adenopathy, lung
  involvement

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When to consider hospitalizing a patient with
gout?

• To distinguish gout from septic arthritis
• Joint fluid analysis
• Empiric antibiotics until diagnosis is clear
• Repeated synovial fluid analysis if needed for
  culture, urate crystals, cell counts
• To control pain
• Aspiration of joint fluid may help
• Gout is one of the most painful conditions

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Non Drug Therapy in Gout

• Reduce high purine foods in diet
• Reduce alcohol and high fructose drinks
• Weight loss to decrease urate levels
• Hydration
• Diet high in fiber, vitamin C, folate
• Replace medications that reduce uric acid
  excretion whenever possible

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Diet Issues

• High purine animal and fish sources
• Red meat, meat extracts, organ meats, seafood
• Yeast products baked goods and beer
• Mushrooms, spinach, asparagus, cauliflower
• Legumes peas, dried beans

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Drugs for Acute Gout

• NSAIDS
• First line analgesic/antiinflammatory
• Ibuprofen and Naproxen better tolerated than
  indomethacin dont use aspirin
• Start at higher dose and taper over 1 week
• Side effects as usual
• Caution in elderly
• Dont use in anticoagulated patients
• Colchicine (oral)
• Most effective if started 12-36 hours after onset
• Lower doses reduce side effects (0.6 mg tid)
• Side effects GI, bone marrow suppression,
  myopathy, neuropathy, dermatitis, urticaria,
  alopecia, purpura
• Myelosuppression can be severe at high doses
  reduced with a short course
• Caution when using other CYP3A4 inhibitors
• Reduce dose for renla or hepatic dysfunction
  avoid if on dialysis
• Caution in elderly

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Drugs for Acute Gout

• Corticosteroids (oral)
• For polyarticular gout when NSAIDS
  contraindicated
• Side effects
• Corticosteroids (intraartiular injection)
• For monoarticular gout when NSAIDS not ideal
• Side effects risk for damage to nerves,
  tendons, vascular structures joint infection
  risk usual oral steroid risks
• Rule out infectious cause before injecting join
• Opiates
• For severe pain
• Oral combinations of oxycodone, hydrocodone,
  codeine
• Severe cases morphine IV or SC
• Short term - until inflammation resolved

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Drugs to Prevent Gout and Complications of
Hyperuricemia

• To prevent growth of crystalliine deposits
• Deposits can lead to chronically stiff, swollen
  joints and debilitating arthritis
• To reduce tophi
• To prevent flare recurrence
• 60 flare again in 1 year, 78 within 2
• Subsequent attacks may last longer, involve more
  joints
• To prevent uric acid stones
• Occurs in 10-40 of persons with gout
• Goal is to reduce urate lt6 mg/dl

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Drugs to prevent gout and complications of
hyperuricemia

• Allopurinol
• Start 100-200 mg/d, increase by 100 mg.d every
  1-4 weeks reduced dose for CKD
• Not in acute attack, concurrent colchicine may
  reduce risk for flare
• Watch for hypersensitivity syndrome
• Other side effects rash, fever, headache,
  uritcaria, interstitial nephritis
• LFTs and CBC monitored
• Febuxostat
• Start 40-80 mg/d increase to achieve goal urate
  level
• Steady state urate after 2 week use
• LFT abn, diarrhea, headache, nausea, rash
• No dose adjustment needed in mild to mod CKD

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Other Drugs to reduce Uric acid level

• Rasburicase
• To prevent tumor lysis
• Not if G6PD deficient
• Start 24 hours before chemo
• Probenicid
• 0.5-2 mg /day divided 2X/day, dose adjust until
  urate level normalizes
• Uricosuric use only if underexreter
• Dont use with aspirin
• Increases methotrexate toxicity
• Rare anaphylaxis
• Not effective in pts with signif CKD

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Drugs to prevent Gouty attacks

• Colchicine (oral)
• Dose and use depends on cr clearance avoid if
  lt10 ml/min
• Continue for 6 months after serum urate lt6 or
  until tophi disappear
• Use caution with other CYP3A4 inhibitors
• May need to dose reduce with calcium channel
  blockers
• Side effects GI intolerance, bone marrow
  suppression, dermatitis, urticaria, alopecia,
  purpura
• Myopathy, neuropathy may increase with renal
  disease or with statin use
• Avoid in severe liver disease

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Indications for long term drug therapy to prevent
gout and complications of hyperuricemia

• At least 2-3 acute attacks of gout
• Tophaceous gout
• Severe attacks or polyarticular attacks
• Radiographic evidence of joint damage from gout
• Nephrolithiasis
• Identifiable inborn metabolic deficiency causing
  hyperuricemia

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When to think about referring for specialty
consultation

• Consult with a rheumatologist or orthopedist
• When joint sepsis is suspected
• When gout is poorly controlled
• When diagnosis is unclear
• When gout occurs with other forms of arthritis
• To aid in deciding on timing of initiation of
  meds or complicated regimens
• Consult with rheum in pts with inherited
  metabolic disease for patients aged lt20 with gout
• Consult with nephrologist for help managing pts
  with CKD and/or urate nephropathy