gout - all you need for primary care

Dr. Ronan KavanaghDr. Ronan KavanaghConsultant RheumatologistConsultant Rheumatologist

Galway ClinicGalway Clinic

Severe pain big toe 3 days

Just returned from golfing trip Thailand

PMHx: Hypertension

Thiazide diuretic

A Medical Colleague in

his 50’s

InvestigationsWCC 13ESR 50, CRP 60Uric acid 325 (normal)

InvestigationsWCC 13ESR 50, CRP 60Uric acid 325 (normal)

Uric acid levels normal in 30-50% acute attacks

Uric acid levels normal in 30-50% acute attacks

What about the normal uric acid?

What about the normal uric acid?

IF URIC ACID NORMAL, REPEAT 2 WEEKS AFTER AN

ATTACK

IF URIC ACID NORMAL, REPEAT 2 WEEKS AFTER AN

ATTACK

What about this?

Treatment?

Treatment of Acute Gout

Treat early

Encourage oral intake fluids

Full dose NSAID

Prednisolone 30-40mg til attack settles then rapid taper

Colchicine: 1mg stat and 500mcg 6hrly til settles

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Joint aspiration and injection

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It is possible to find crystals in asymptomatic joints between attacks

Diagnosis

Uric acid may be normal (check after 2

weeks)

Don’t treat hyperuricaemia

Aspirate joints for definitive diagnosis

Can aspirate joint after event

Any other tests?

Renal function

Weight measurement

Don’t forget the BP!

Fasting lipids

• (Hypertriglyceridaemia)

Fasting glucose / dipstick urine

Uric acid excretion?

6 weeks later6 weeks later• The patient returns and reports four

additional acute gouty attacks that responded to colchicine

• On Allopurinol 300mg once daily

• ‘Worse’ since starting

• BP is 130/80 with lisinopril.

• The patient returns and reports four additional acute gouty attacks that responded to colchicine

• On Allopurinol 300mg once daily

• ‘Worse’ since starting

• BP is 130/80 with lisinopril.

COMMON REASONS FOR LACK RESPONSE

Starting Allopurinol during an attack

No prophylaxis

Stopping allopurinol during an attack

Dose of allopurinol too low

URIC ACID 390 (NORMAL RANGE <

430)

TARGET URIC ACID

EULAR suggest < 360 umol/l1

British Society for Rheumatology < 300 umol/l2

(‘normal’ lab range <430)

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Allopurinol

MEDICAL MANAGEMENT OF CHRONIC GOUT

MEDICAL MANAGEMENT OF CHRONIC GOUT

Start allopurinol gently (ideally not during acute attack)

100mg od after a week to 300mg od

Co-prescribe prophylaxis for 1st 6 weeks

Colchicine 500mcg odLow dose NSAID (avoid in this patient)Low dose steroids (Pred 5-7.5mg daily)

Check Urate after a month

Most require 300MG – 500mgMost require 300MG – 500mg

Doses of up to 800MG may be requiredDoses of up to 800MG may be required

Increase monthly dose depending on uric acid Increase monthly dose depending on uric acid levelslevels

Typically 100MG – 300MG – 500MG – 600MG – Typically 100MG – 300MG – 500MG – 600MG – 800MG800MG

Keep uric acid < 300Keep uric acid < 300

ALLOPURINOL

Allopurinol sensitivityRare

Severe reactions < 0.1%

More common in patients with renal impairment*

More common higher doses

Skin rashes 3%

Mild LFT abn.

Stop if rash occurs

Avoid with Azathioprine and mercaptopurine*Arthritis Rheumatism 2009, S60; 761

Treatment adherence rates after 1 year

Pharmacotherapy. 2008;28(4):437-443

What about alcohol?

Alcohol reduces renal urate excretion

Increasing hepatic production of uric acid

Dehydration and acidosis

Reduces metabolism of allopurinol to active metabolite

Beer contains guanosine which is converted to urate

Alcohol reduces renal urate excretion

Increasing hepatic production of uric acid

Dehydration and acidosis

Reduces metabolism of allopurinol to active metabolite

Beer contains guanosine which is converted to urate

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I suppose I’ll have to give up the drink then?

O.R. = 2.5 O.R. = 1

O.R. = 1.6

Choi HK et al. Lancet 2004; 363: 1277–81

x2 x2

x2

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I might as well drink wine.......

O.R. = 2.5 O.R. = 1O.R. = 1.85

X2 X2X2

Advise to drinkers

•Don’t drink to excess if your father had gout

•If you drink to excess don’t forget to eat

•If you do eat, rethink your diet

•If you are on allopurinol watch yoour urate when you drink!

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Low purine diets

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What about diet?

Dietary trends increasing prevalence of Gout Associated with Obesity and Insulin resistance

Low purine diet Unpalatable Small reduction uric acid (max 10%)

Current diet focus on: Wt management Moderation of meat and seafood Restriction non complex carbohydrates

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Diet continued

Regular intake of low fat dairy products reduces attacks

Drinking 5-8 glasses water in 24hrs before attack reduces attacks by 40%

Not as important if gout well controlled with meds

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A word about tophi

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Gout and renal impairment

Uric acid 640

Creatinine 150

eGFR = 30mls/min

47% of patients with gout in general practice have eGFR < 60 mls /min

Gout in renal failureNeed to reduce dose of Allopurinol in renal

failure

Reduced dose means reduced efficacy

Risk of Allopurinol toxicity higher in pts with renal failure (still rare)

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Asymptomatic hyperuricaemia

Do we need to treat hyperuricaemia?

Strongest risk factor for gout but

0.5% yearly inc. if uric acid 420-530 μmol/l

4.5% if uric acid > 540 μmol/l

Double risk of uric acid renal stones

Renal damage?

Hypertension?

Cerebrovascular disease?

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“Evidence does not yet support the general treatment of asymptomatic hyperuricaemia to reduce cardiovascular risk”

NEJM 2008;359:11811-21

Alternatives to allopurinol

Probenecid 250mg bd increasing to 1g tds

Less effective if renal impairment

Losartan

Fenofibrate (Lipantil)

Vitamin C

Uricase

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Take home pointsUric acid may be normal (check after 2 weeks)

Check Uric acid after a month on treatment

Aim for Urate < 300 with treatment

Many patients need more than 300mg allopurinol

Don’t start Allopurinol during an attack

Don’t stop Allopurinol during an attack

Co-prescribe NSAID / low dose colchicine for 1st 6 weeks

Look for metabolic syndrome

Take home points

Consider reducing dose allopurinol in renal impairment

Consider Febuxostat in allopurinol sensitivity

80mg starting dose increasing to 120mg if necessary

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Musicians clinic

‘‘Keeping the show Keeping the show on the road’on the road’

Musicians Health Musicians Health ConferenceConference

20122012

‘‘Keeping the show Keeping the show on the road’on the road’

Musicians Health Musicians Health ConferenceConference

20122012

Saturday October Saturday October 13th 201213th 2012

Radisson Hotel Radisson Hotel GalwayGalway

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