gout topic discussion · guidelines for management of gout. part 1: systematic nonpharmacologic and...

Gout Topic Discussion

Rachel Dietsche

The Disease

Historically known as the ‘rich

mans disease’

Prevalence in the US is almost 4%

Tophi-deposited MSU crystals and

inflammation

Unknowns:

Why first MTP?

Why acute attacks result from

trauma or urate lowering

therapy?

Why spontaneous resolution?

Etiology

Result of high uric acid levels

Impaired excretion of uric acid

Overproduction of uric acid

High intake of purine-rich food

Etiology

Nonmodifiable Risk Factors

Male

Older in age

Pacific Islander ethnicity

Genetic loci SNPs

Modifiable Risk Factors

Obesity

Diet

Alcohol

Fructose/sucrose beverages

HTN

Diuretics

CKD

Cyclosporine, ASA

Pathophysiology

o Monosodium urate

(MSU)crystals

o Found in synovial fluid

o First metatarsal

phalangeal joint

o Inflammation

o Neutrophils

o Monocytes

o lymphocytes

Clinical Presentation

flare

painful

red

swollen

warm

Disabling

Skin desqua-mation

WBC 10,000-100,000

Mostly neutrophils

Urate ≥ 6.8mg/dL

Dual energy computed

tomography (DECT)

Urate vs calcium

Diagnosis

Scoring System

Laboratory Analysis

Physical Findings

Treatment Guidelines and Alternatives

1st Line Urate Lowering Therapy

Allopurinol

or

Febuxostat

2nd Line Urate Lowering Therapy or

Add-Ons

Probenacid

or

Fenofibrate

or

Losartan **Colchine for treatment of flares or prophylaxis

during intiation of URL**

Drug of Choice and Monitoring

Allopurinol Initial 100mg daily

Titrate 100mg Q 2-4 Weeks

Screen for HLA-B*5801 variant

Chinese, Thai, Korean

CrCL 10-20: 200mg/d

3-10: 100mg/d

<3: 100mg/d extended intervals

Side Effects Most Common

Rash

Gout flare

Nausea/vomiting

Possible diarrhea and increased

hepatic enzymes

Rare

Bone marrow suppression

Alternative Drugs and SE/Monitoring

Anakinra

IL- 1 Antagonist

100mg SQ daily for around 3 days to treat an acute flare

CrCl <30: SQ every other day

Side Effects

Most common

Head ache

Vomiting

Infection

Injection site reaction

May increase cholesterol and hepatic enzymes

References

Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American college of rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res. 2012;64. 1431.

Qaseem A, Harris RP, Forciea MA, et al. Management of acute and recurrent gout: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2017;166(1)58-68.

Becker MA, Gaffo AL. Clinical manifestations and diagnosis of gout. UpToDate. Last updated 10/09/2018. Accessed 12/05/18

Allopurinol: drug information. UpToDate. Accessed 12/06/18

Anakinra: drug information. UpToDate. Accessed 12/07/18.