management of gout dr jennifer hamilton consultant rheumatologist queen elizabeth hospital gateshead
TRANSCRIPT
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Management of Gout
Dr Jennifer HamiltonConsultant RheumatologistQueen Elizabeth Hospital
Gateshead
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Overview
• Background• Pathophysiology of gout• Gateshead Gout Guideline
– Patient information– Costings
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Why do we need a gout guideline?
• Gout prevalence is increasing-Diet-Obesity-Ethanol use-Increased use of low dose
aspirin• Prevalence 4.1% by age of 75
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Treatment options
• Cheap• Tried and tested• Opportunity to reduce utilisation of
health resources• Reduce costs as can be largely
managed in primary care
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MetabolismSynthesis
Dietary purine
Purine synthesisBody purinenucleotides
Tissue nucleic acids
Purines
Uric acid
Elimination
Intestinalexcretion
Renal excretion
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Urate crystal formation
• Urate more soluable in plasma, synovial fluid and urine
• At a concentration above 0.42 plasma is supersaturated with urate
• Urate and uric acid soluability fall with decreasing temperatures
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Factors affecting urate crystal formation
• Concentration of urate at site of crystal formation (dehydration)
• Local temperature (? Why big toe affected)
• Presence or absence of substances maintaining urate in solution
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What causes the inflammation
• MSU crystals recognised by innate immune system
• Uptake of MSU by phagocytic cells• MSU activates NALP3 inflammation• IL 1ß released which mediates the
autoinflammatory response
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Acquired causes of hyperuricaemia
Overproduction
Nutritional Purine consumptionAlcoholFructose administration
Haemopoeitic Myeloproliferative disordersPolycythaemia, leukamia and infectious mononucleosis
Systemic disease psoriasis
Under excretion
Nutritional Alcohol
Renal disease
Drugs
Metabolites / hormones Vasopressin, lactic acidosis, ketosis, angiotensin
Misc Myxodema, respiratory acidosis, toxaemia of pregnancy, myocardial infarct, hyperparathyroidism
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Drugs mondifying renal excretion of urate
Increased excretion Decreased excretion
High dose aspirinPhenylbutazoneProbenicidSulfinpyrazoneBenzbromaroneDiflunisalAzapropazoneRadiographic contrast mediaOral anticoagulantsAdrenal corticosteroidsAllopurinolFeboxustatlosartan
Low dose aspirinLow dose phenylbutazoneThiazide diureticsFurosemideEthambutolPyrazinamide nicotinic acid
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Case 1
• 40 year old male• Normal BMI• No significant past history apart
from 2 previous episodes of gout in 10 months
• Family history of gout• Presents with inflamed big toe• Currently on no medication
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Management
• NSAIDs- Assess risk factors• Colchicine 500mcg bd
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Review at 4-6 weeks
• Bloods for urate, U&E, glucose and lipids
• BP• Lifestyle advice• Cardiovascular risk profile
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Allopurinol ?
• Yes recurrent acute gout (3 attacks in 12 months)
• Also start if – Tophi– GFR <80– Uric acid stones – Need to continue diuretics
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Tips• Wait until acute attack has settled at least 2
weeks and bring urate levels down slowly
• Rapid lowering of urate may disrupt surface of crystals and trigger IL1 induced inflammation
• Initial allopurinol dose 100mg daily• Titrate by 100mg every 3-4 weeks• Don’t stop during acute flares• Aim for urate less than 0.3
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Tips 2
• Colchicine prophylaxis signficantly reduces flares at 6months
• Serum urate levels fall within 2 days and are in steady state at 2 weeks therefore repeating level at 3-4 weeks appropriate
• Lowering serum urate to less than 0.36 eliminates recurrent attacks in 86% of patients.
• BSR suggest lower than 0.30 as urate less likely to come out of solution and tophi shrink faster.
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Neil StanleyGPST3
Patient information and Resources in Gout
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1. Key points for patient education / advice
2. Resources for patients
3. Cardiovascular risk
Aims
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1) Eat less high urate containing foods • Beef• Pork • Seafood• Offal• Liver• Kidney• Oily fish• Yeast containing food (bovril, marmite) • Lamb
• Avoid sugary fizzy drinks (fructose containing)• -metabolism can lead to urate production
Key points for Patient education
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2) Alcohol consumption• Drink within recommended government levels–but may be advisable to cut down
even within these levels• All alcoholic drinks implicated except low to moderate wine consumption
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3) Lose weight• If overweight• (?referral to weight management courses)
4) Medication issues• Complaince
–Concept of preventer vs. reliever medication
–Take your preventer medication every day
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• Allopurinol can trigger a flare up of gout when started or dose increased– Explain importance and role of taking
nsaid/steroid/colchicine at these times– Who to contact how and why
• DO NOT STOP DURING FLARE UP
• Continue to take after acute symptoms resolve – they may recur if withdrawn
• Take every day (preventer)
Allopurinol
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Resources for patient information
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• The Gateshead gout guideline PIL
Information leaflets
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• Arthritis research council Gout PIL
• (Downloadable or can order from www.arthritisresearchuk.org.uk)
Information leaflets
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• www.arthritisresearchuk.org.uk
• www.patient.co.uk
• www.arthritiscare.org.uk–(call 0808 800 4050 - free)
Websites
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Cardiovascular risk
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• Gout is associated with lifestyle factors that can increase vascular risk
• Hyperuricaemia is associated with cardiovascular disease (does lowering urate reduce risk??)
• All patients with gout should be risk stratified using standard assessment - BP, Bloods, history and JBS calculation - and appropriate interventions considered (lifestyle and medication)
Primary prevention
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Pharmacology and Evidence base
Anne- Marie Bailey
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Colchicine
• Alkaloid• Interferes with neutrophil migration via
action on microtubules• Inhibits tyrosine phosphorylation in
neutrophils in response to MSU• Inhibits NALP 3 inflammation in
moncytes• Reduces IL1 production (key
proinflammatory cytokine)
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Evidence Base
ColchicineAcute flare • NNT of 3 to reduce pain after 48 hours• NNT of 2 to reduce symptoms after 48
hoursProphylaxis • Reduction in number of acute flares from 2.91 to
0.52 (n= 43 p=0.008) over 3 month period• Much larger study (n= 540 over 20yrs)
demonstrated excellent results in 82% of patients with only 5% unsatisfactory
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Risk factors for colchicine toxicity
• Renal or hepatic impairment– avoid if possible or if no alternative therapy
exists for patients with creatinine clearance < 30mL/minute, extend the interval between colchicine treatment courses to 2 weeks during an acute gout flare
• Increasing age • Gastrointestinal or cardiac disease • High doses of colchicine (> 1.5mg daily)• Prescribing colchicine concurrently with
drugs that inhibit CYP3A4 or P-gp
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Strong inhibitors of CYP3A4
May need to stop colchicine or reduce dose if on following drugs:-
• Antiarrhythmics - digoxin• Antibiotics - clarithromycin, erythromycin• Antifungals - fluconazole, itraconazole
ketoconazole• Antiretrovirals - amprenavir, atazanavir,
fosamprenavir, indinavir, ritonavir, saquinavir• Calcium-channel blockers - diltiazem,
verapamil • Fibrates - fenofibrate, gemfibrozil• Grapefruit juice• Immunosuppressants - cyclosporin, tacrolimus• Statins - atorvastatin, fluvastatin, pravastatin,
simvastatin
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Mechanism of action of allopurinol
adenosine inosine hypoxanthine xanthine Uric acid
Allopurinol
XO XO
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Contraindications to allopurinol
• Previous hypersensitivity• Azathioprine (extreme caution
metabolism of aza and 6MPU decreased leading to increased risk of toxicity)
• Reduced dose but not contraindicated in patients with renal impairment
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Case continued……
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Progress
• Started on allopurinol 100mg with colchicine 500mcg bd
• Phones 2 weeks later acute pain and swelling right knee
• Options?
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Management
• Check for signs of sepsis
• Pyrexia• Systemic upset• Can be very difficult to differentiate between sepsis and gout
• If in doubt discuss with on call rheumatologist
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• Bloods• Aspirate joint and send for
polarised microscopy (best done in secondary care)
• Inject kenalog 40mg• Urate > 0.3 increase allopurinol
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Progress 2
• Phones 1 week later• Rash widespread
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Options
• Feboxustat 80mg increasing to 120mg after 2-4 weeks if urate remains up
• Non purine inhibitor of xanthine oxidase
• Can be used in allopurinol hypersensitivity
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Feboxustat adverse effects
• Liver enzyme elevation• Increased risk of GI adverse effects
compared to allopurinol• ? Increased risk of vascular events
– Placebo 0, feboxustat 40mg 0, feboxustat 80 1.09, allopurinol 0.97 events per hundred patient years
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Interactions
• Azathioprine• 6 Mercaptopurine• Increases theophylline
concentration
• NICE guidance not currently recommended for patients with significant renal and cardiovascular disease.
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52 year old man10 week history of pain and swelling in forefeetSpreading to involve MCP, PIP joints elbows and wristsPast history of hypertension
Examination
Bilateral swellings over KnucklesNodular swelling over right ulna and dorsum of feet
Beware other presentations
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Investigations ESR 87mm/hrRF 1/40Erosions on radiographs
Case 2 (Cont)
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Case 2 (Cont)
White tophaceous fluid aspirated from small jointMonosodium urate crystals in synovial fluid
Urate: 0.63mmol/l
Progress
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Gout starts in first MTP in 50%Polyarticular at onset in 10%Tophi may have similar distribution to RA nodules
Case 1 (Cont)
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No clinical critera have a positive predictive value greater than 70%
In patients where fluid unavailable for microscopySuggestive features include
• Classic history of monoarticular attacks, asymptomatic• Between• Maximum inflammation within 24 hours• Unilateral first MTP joint• Hyperuricaemia• Typical tophi• Erosions consistent with gout
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JG Age 78
Case 3
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History
Rheumatic Heart diseaseCCF on high dose diureticsRenal failure- creatinine 200, Urea 35NSAIDs contraindicatedColchicine in low dose led to diarrhoea
What to do?
Case 2 (Cont)
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Is treatment required?
Are there any contributing factors that can be removed?
DiureticsLow dose AspirinObesityAlcohol
Lesions usually trouble freeSevere attacks uncommon but at high risk of complications
Case 2 (Cont)
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Options for treatment?
Low dose colchicineCorticosteroids- Oral IA, IMAllopurinol
Case 2 (Cont)
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In one GP practice
• 31 patients presented over a 3 month period
• 12 patients were seen more than once-only 1 of whom was on allopurinol
• Only 10 patients were on or were started on prophylaxis
• Only 6/25 patients with known gout were on allopurinol
• None referred to secondary care
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In secondary care over 6 monthsNo of samples No of patients
Crystals not seen
215
Pyrophosphate 44
Uric acid 30 27
Mixed pyrophos/ urate
2 2
Cholesterol 2 2
Unidentifiable 1 1
Total 294
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Cost of treatment vs Activity costs
Cost of 6 months treatment (Based on Drug Tariff costs at Jan 2012)
• Allopurinol 300mg 1 daily £8.00• Colchicine 500micrograms twice daily
£107• Febuxostat 80mg daily for 2-4 weeks then
120mg daily £159Activity costs
• Attendance at out patient clinic with procedure (joint aspiration) £400
• Same procedure with 48hr or less hospital stay £1400
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Febuxostat and NICE
• Recommended as an option for the management of chronic hyperuricaemia in gout only for people who are intolerant of allopurinol or for whom allopurinol is contraindicated within licensed indication
• Expected incidence of Allopurinol intolerance or hypersensensitivity is 5%
• 43 patients in Gateshead estimated to require Febuxostat but only 2 patients started to date since NICE guidance (September 2008)
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Other options
• Probenicid• Sulphinpyrazone• Benzbromarone• Uricase• New IL1B inhibitors in development• Pegloticase (uric acid specific
enzyme)
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Challenges
• Compliance• Organising regular review for
titration• Presentations out of hours and
minimising A&E attendance
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Conclusion
• Gout is undertreated• The majority of patients will
respond to inexpensive drugs• Optimal treatment will lead to long
term benefits to health community and individual patients both in terms of improved health and reduction in utilisation of resources