Gout

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Diagnosis

  • Which joints
    • Gout typically affects the first metatarsophalangeal joint (big toe) then midfoot, ankle, knee, fingers, wrist and elbow joints
    • Although can affect any joint
    • Usually monoarticular but can be oligoarticular or rarely polyarticular
    • Lower limb joints are affected more frequently than upper limb joints
  • Symptoms and rapidity of onset
    • Severe pain with associated swelling, redness, warmth and tenderness
    • Usually reaches maximum intensity within 24 hours
    • Ability to mobilize and impact on work and functioning
  • The frequency and duration of attacks
  • Rule out arthritis
    • swelling
    • redness
    • warmth
    • pain on passive movement
    • typically of the first metatarsophalangeal joint although any joint can be affected
  • Associated comorbidity can increase the risk of developing gout or hyperuricaemia
    • Obesity
    • hypertension
    • hyperlipidaemia (especially hypertriglyceridaemia)
    • diabetes mellitus
    • congestive cardiac failure
    • ischaemic heart disease
    • chronic kidney disease
    • osteoarthritis
    • myeloproliferative disease
    • severe psoriasis
    • sickle cell anaemia
    • glycogen storage diseases
    • history of renal colic or nephrolithiasis
  • Check kidney/liver function: this may affect treatment choice
  • Any previous drug interventions tried
  • Red flags:
    • The diagnosis is uncertain, there is a suspicion of an underlying systemic illness (for example rheumatoid arthritis or connective tissue disorder)
    • Pregnancy
    • Under 30 years (may suggest renal or enzymatic disorders and is often associated with genetic causes. More aggressive investigation and drug treatment may be necessary)
    • Treatment failure
    • Complications are present, including urate kidney stones, urate nephropathy, recurrent urinary tract infection, joint damage or troublesome tophi
    • Fever
    • Recent localised surgery or intervention

Medications which may cause gout

The following medications raise uric acid levels

  • ACE inhibitors
  • beta-blockers
  • ciclosporin
  • diuretics
  • pyrazinamide
  • ritanovir
  • tacrolimus
Medication  Recommendation
ACE for hypertension ACEs increase uric acid whereas Ca blockers decrease uric acid - switch to amlodipine 
person with hypertension taking a diuretic changing to an alternative antihypertensive
person with heart failure taking a diuretic continue diuretics during an acute attack, if using a nonsteroidal anti-inflammatory drug (NSAID) for pain relief, monitor renal function closely.
allopurinol/febuxostat Do not stop during acute attack


Initial blood test

* WCC - in septic arthritis the white cell count may be raised

* eGFR – to ensure medication dose safe

* uric acid – baseline for gout

Treatment

  • Self-care
    • Rest and elevate the limb
    • Avoid trauma to the affected joint
    • Keep the joint exposed and in a cool environment
    • Consider the use of an ice pack or bed-cage
  • Discuss lifestyle
    • weight loss
    • exercise
    • diet; avoid purines, red meat, seafood, high intake of fructose, particularly sugary drinks
    • alcohol consumption
    • increase fluid intake
  • Medication
    • Naproxen: 750 mg stat followed by 250mg every 8 hours until 2 days after symptoms have passed & PPI
    • Indomethacin: 50mg three or four times daily until symptoms subside
    • Colchicine: 1 mg (2 tablets) to start followed by 500 micrograms (1 tablet) after 1 hour. No further tablets should be taken for 12 hours. After 12 hours, treatment can resume if necessary with a maximum dose of 500 micrograms (1 tablet) every 8 hours until symptoms are relieved. The course of treatment should end when symptoms are relieved or when a total of 6 mg (12 tablets) has been taken. No more than 6 mg (12 tablets) should be taken as a course of treatment. After completion of a course, another course should not be started for at least 3 days (72 hours).
    • Can add paracetamol as an adjunct for pain relief

Advice patient to return if symptoms get worse, or if there is no improvement after 2 days

Book BT for uric acid HbA1c, renal function & lipids in 4 weeks followed by a review 

 

4-week review 

  • Check BT
  • Identify and manage underlying conditions such as hypertension, diabetes, dyslipidaemia or renal impairment, and assess the person's overall cardiovascular risk. (gout has been identified as an independent risk factor for coronary artery disease and renal disease mortality)
  • Discuss lifestyle:
    • weight loss
    • exercise
    • diet; increase purines, red meat, seafood, high intake of fructose, particularly sugary drinks
    • alcohol consumption
    • increase fluid intake
  • Advise that acute flares of gout should be treated as early as possible. (Consider providing an advance prescription of effective treatment for future attacks of gout.)

 

Urate-lowering treatment (ULT)

 

  • Advise the use of urate-lowering therapy to people with
    • Two or more attacks of acute gout in 12 months
    • Tophi
    • Chronic gouty arthritis
    • Joint damage
    • renal impairment (eGFR less than 60 ml/min)
    • A history of urinary stones
    • Diuretic use
    • Young age of onset of primary gout
  • Patient counselling points
    • Urate-lowering medication is normally lifelong and regular monitoring is needed
    • Allopurinol or febuxostat may increase the risk of acute attacks of gout just after initiating treatment, and for some weeks afterwards
    • start anti-inflammatory treatment as soon as possible and not to stop their allopurinol or febuxostat during acute attacks
    • start urate-lowering therapy after the acute attack has resolved. In circumstances where attacks are so frequent that this is not possible, the initiation of allopurinol can be considered before inflammation has completely settled

Allopurinol

  • first-line
  • 100mg od then where tolerated uptitrate every four weeks until the serum uric acid (SUA) level is below 300 micromol/L and then continue monitoring every 4 weeks for the first 3 months
  • renal impairment:startin dose is lower then uptitrate only if tolerated and neccessary. Monitor renal function.
    • eGFR 30-60 mL/min/1.73m2 : 50 mg once a day (allopurinol 50 mg tablets are not available, so when providing a 50 mg dose check that the 100 mg tablets are scored)
    • eGFR 16-30 mL/min/1.73m2 - 50mg every 2 days
    • eGFR 5-15 mL/min/1.73m2 - 50mg twice weekly
    • eGFR less than mL/min/1.73m2 - 50mg per week
  • Allopurinol treatment should not be started until an acute attack of gout has completely subsided, as further attacks may be precipitated
  • In the early stages of treatment with Allopurinol, as with uricosuric agents, an acute attack of gouty arthritis may be precipitated. Therefore it is advisable to give prophylaxis with a suitable anti-inflammatory agent or colchicine for at least one month
  • If acute attacks develop in patients receiving allopurinol, treatment should continue at the same dosage while the acute attack is treated with a suitable anti-inflammatory agent
Rx
Allopurinol 100mg OD for 4 weeks then BT
Colchicine 500mg BD for at least a month 

Febuxostat

  • second-line therapy
  • Check liver function tests prior to initiation
  • Start 80 mg once daily
  • Monitor after 2–4 weeks, if serum uric acid is greater than 6 mg/100 mL (300 micromol/L) then increase dose up to 120 mg once daily
  • A prior history of hypersensitivity to allopurinol and/or renal disease may indicate potential hypersensitivity to febuxostat
  • The risk of gout flare is particularly high when initiating febuxostat
  • Consider prescribing colchicine when initiating or increasing the dose of a ULT as prophylaxis against acute attacks secondary to ULT, and continue for up to 6 months
  • If colchicine cannot be tolerated, consider a low-dose NSAID or coxib with gastroprotection as an alternative provided there are no contraindications.

Stopping ULT

  • After some years of treatment, once serum uric acid target is reached and clinical 'cure' has been achieved (acute attacks have stopped and tophi have resolved), consider reducing the dose of ULT to maintain the serum uric acid level between 300-360 micromol/L
  • Although in most people ULT will be required lifelong, consider stopping allopurinol or febuxostat only in people who have achieved a clinical 'cure', successfully addressed modifiable risk factors and had a normal serum uric acid level for many years
  • If considering discontinuing urate-lowering medication, explain that there is no certainty that a further episode of gout will not recur
  • Continue to regularly monitor serum uric acid levels
  • Consider providing an advance prescription of effective treatment for future attacks of gout but advise them not to start allopurinol or febuxostat immediately if an acute attack develops, and to seek medical advice
  • Stress the importance of a healthy lifestyle and avoidance of trigger factor

 

benzbromarone and probenecid

  • available in secondary care settings and should only be prescribed by specialists

References

NICE

BNF

Arthritis.org

Nhs.uk

Webmd.com

Allopurinol Ciclosporin pyrazinamide ritanovir febuxostat Naproxen Indomethacin Colchicine benzbromarone probenecid

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