Gout%20Treatment

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Gout Treatment

• Megan Chan, PGY-2
• UHCMC 2015

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Gout

• Acute gouty arthritis monosodium urate crystals
  in synovial fluid leukocytes
• Serum urate 6.8 insoluble in extracellular
  fluids
• Tophi painless nodular deposits of monosodium
  urate crystals in tissues
• Chronic urate nephropathy
• Crystals deposit in renal medullary interstitium
• Uric acid nephrolithiasis

https//www.hss.edu/images/corporate/X-ray-Toe-Joi
nt-with-Tophus-with-Calcification-Gout.jpg
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2012_2/1220Tophus/2aj.jpg
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chart.png
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Risk Factors

• Obesity
• HTN
• HLD
• HF
• Insulin resistance
• Hyperglycemia
• Renal disease
• Older age
• Genetics
• High purine/fructose diet
• Alcohol
• Meds loop thiazide diuretics, acetylsalicylic
  acid, ASA

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Usually Monoarticular

• In order of frequency
• 1st metatarsophalangeal joint Podagra
• Ankle
• Heel
• Knee
• Fingers
• Elbows

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Lifestyle Modifications

• Diet
• Weight loss
• Alcohol cessation

Mead T, Arabindoo K, Smith B. Managing gout
there's more we can do. J Fam Pract.
201463(12)707-13.
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Diagnosing gout

• How good is joint aspiration to look for
  negatively birefringent crystals?
• 85 sensitive, 100 specific
• Is imaging necessary to diagnose gout?
• No, but if you got it you may see subcortical
  bone cysts, tophi, erosions

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/AA00BB07-78FF-45BD-90119D22B17E6D32.jpg
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e/acr2011/fig10.jpg
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Acute Gout

• How useful is a uric acid level during an acute
  flare?
• Helpful if elevated but may be falsely normal/low
  (25-40 of pts) 2/2 cytokine effect
• So when is the most accurate time to check serum
  uric acid levels?
• 2 weeks after complete resolution of a flare

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Acute Attacks

• Initiating treatment within 24 hours has been
  associated with decrease pain and shorter
  duration of symptoms.
• For mild-moderate pain involving a few small
  joints or 1-2 large joints ? Monotherapy
• NSAIDS
• Naproxen 500mg BID, Indomethacin 50mg TID
• Colchicine (unless gt36 hrs after symptom onset
  due to diminished benefit)
• Corticosteroids
• Prednisone 30-50mg daily ? taper over 7-10 days
  post flare to prevent rebound attacks

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Acute Attacks

• For severe pain (gt6 out of 10) and/or
  polyarticular (4 joints in more than 1 region of
  the body) ? Combination therapy
• Colchicine NSAID
• Colchicine corticosteroids
• For NPO pts, can give intraarticular/IV/IM
  steroids or SQ ACTH
• Continue acute treatment until attack resolves
  (5-14 days)

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Mead T, Arabindoo K, Smith B. Managing gout
there's more we can do. J Fam Pract.
201463(12)707-13.
12
Chronic Gout Tx

• Criteria for Urate Lowering Therapy (ULT)
• Presence of tophi
• 2 acute attacks per year (some tx after 1
  flare)
• CKD stage 2-5
• Hx of urolithiasis
• Start ULT anti-inflammatory prophylaxis AFTER
  an acute gout attack resolves.
• If on ULT prior to a gout attack, continue
  regimen.
• If gout symptoms persist despite serum urate
  level lt 6.0, increase ULT to obtain a target of
  lt5.0.

When do you start ULT therapy?
What do you do with ULT therapy if pt is on it
and has an acute attack?
What do you do if your pt still has symptoms when
their serum urate is lt6.0?
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Urate Lowering Therapy

• Allopurinol first line
• xanthine oxidase inhibitor
• Consider Rheum involvement if GFR lt50
• Febuxostatreports of hepatic failure but not
  commonly seen clinically
• xanthine oxidase inhibitor
• Use in renal insufficiency
• Probenecid alterative to those with xanthine
  oxidase allergy or intolerance
• Increases urinary uric acid secretion
• Hardly used because its difficult to tolerate
  and increases risk of nephrolithiasis

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Allopurinol Hypersensitivity

• 1 in every 1000 patients
• SJS/TEN, eosinophilia, leukocytosis, fever,
  hepatitis, renal failure
• High mortality (20-25) and no cure!
• Screen for HLA-B5801 allele in high risk groups
• Koreans with CKD stage 3 or worse
• All Han Chinese Thai patients

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Mead T, Arabindoo K, Smith B. Managing gout
there's more we can do. J Fam Pract.
201463(12)707-13.
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Anti-inflammatory Prophylaxis

• Should be started with ULT to prevent flares
• Low-dose Colchicine (0.6 daily or BID)
• Low-dose NSAIDS (Indomethacin 25mg BID)
• Oral steroids (lt10mg/day) second line
• Should continue for whichever is greater
• 3 months after target serum urate level is
  achieved in those with no tophi
• 6 months after target serum urate level is
  achieved and tophi have resolved
• Sometimes can take 1-2 years to wean people off
  without flares occurring

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How long should ULT be continued?

• Indefinitely!
• How often should you monitor serum uric acid
  levels?
• Every 2-5 weeks until target is achieved
• Then every 6 months

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Refractory Gout

• If urate does not reach goal lt6mg/dL (or lt5mg/dL)
  at max doses of first-line xanthine oxidase
  inhibitors.
• Add uricosuric agent
• Probenecid, Fenofibrate, Losartan
• Last resort Pegloticase IV pegylated q2 wks
  recombinant form of urate oxidase enzyme that
  converts uric acid to allantoin (water soluble)
• Can develop Ab over time that cause infusion
  reactions
• Investigational Anakinra IL-1 inhibitor
• Note Low adherence rate to gout therapy (lt50
  will take tx as prescribed in their first year).
  Check for this first!

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https//www.hss.edu/images/corporate/Purines-to-Ur
ic-Acid-and-How-Gout-Medications-Work.jpg
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Summary Practice Recommendations

• Prescribe an anti-inflammatory drug when
  initiating ULT (grade A).
• Increase the dose of ULT to achieve a lower
  target of lt5mg/dL if gout symptoms persist
  despite a serum urate level lt6mg/dL (grade B).
• Do not initiate ULT during an acute gout flare.
  However, if already on ULT regimen when a flare
  occurs, do no stop it (grade C).
• Asymptomatic hyperuricemia does not equal gout
  and should not be treated with ULT.
• However some rheumatologist will treat urate
  levels gt13 in young pt to prevent consequences of
  deposition.

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References

• Mead T, Arabindoo K, Smith B. Managing gout
  there's more we can do. J Fam Pract.
  201463(12)707-13.
• UptoDate
• Special thanks to Dr. Pioro for the special Rheum
  insights!