SX:
acute monoarthritis usually.
History:
-
Alcohol intake (As little as 1-2 drinks can precipitate an attack in persons
who are predisposed to gout ).
-
Medications (Among the most common medications that can precipitate acute
gout attacks are thiazide diuretics and cyclosporine. Drugs that can cause
hyperuricemia include other loop diuretics, pyrazinamide, ethambutol, nicotinic
acid, vitamin B12, cancer chemotherapy, low dose salicylates, and levodopa)
-
Renal insufficiency (As renal function declines, so does clearance of uric
acid - uric acid retention; renal insufficiency may thus predispose to gout.
Gout in end-stage renal disease is not the norm, however. Renal function
should also be considered when determining the most appropriate therapies
for management)
-
Metabolic syndrome (The insulin-resistance syndrome is characterized by
hyperlipidemia, hyperuricemia, central obesity, hypertension, and glucose
intolerance)
-
Among the most common medications that can precipitate acute gout attacks
are thiazide diuretics and cyclosporine. Drugs that can cause hyperuricemia
include other loop diuretics, pyrazinamide, ethambutol, nicotinic acid, vitamin
B12, cancer chemotherapy, salicylates (low dose), and levodopa
-
Inherited metabolic disorders (Hypoxanthine-guanine phosphoribosyl transferase
deficiency, phosphoribosylpyrophosphate synthetase overactivity, and
glucose-6-phosphatase deficiency are some heritable disorders that lead to
purine overproduction and thus predispose to gout. Bartter's syndrome,
polycystic kidney disease, and Down's syndrome are some genetic disorders
that can lead to hyperuricemia via decreased renal clearance of urate)
Physical Exam:
-
Very tender, swollen joint, often sensitive to very light touch (e.g., from
a bedsheet)
-
Erythema of soft tissues overlying affected joint; Superficial desquamation
of skin over the affected joint as the attack subsides
-
Tophi present as nodular deposits of monosodium urate with yellowish color,
sometimes with surrounding erythema; they occur in a distribution similar
to rheumatoid nodules on extensor surfaces of extremities, on finger pads,
and along tendons, but may also be seen on the helix of the ear or eyelid.
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| RX:
Advise patients with gout that they should not consume ethanol.
Low purine diet: Consider alterations in diet to eliminate most high-purine
foods from an animal source, including:
-
Organ meats, such as brain, kidney, liver, and pancreas (sweetbreads)
-
Red meat
-
Gravies, consommé, and broth
-
Scallops, anchovies, sardines, and herring
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Milk and eggs
Acute Attacks Rx ("Put out the fire")
-
Indomethacin/Indocin 50 mg tid PO until
all Sx have resolved for 48 hrs.
-
Colchicine 0.5-0.6 mg PO every 1-2 hours
until symptoms subside or GI intolerance occurs (Max 6 mg in 24 hr, and no
more than 1.2 mg/d thereafter). or
IV 1-3 mg initially, then 0.5 mg q6h until relief, intolerable side effects
of abd. cramping or diarrhea occurs, or max of 4 mg IV without improvement.
[2 mg iv diluted in 10-20 mL of normal saline and infused through
a freely flowing IV over 3-5 minutes. May repeat 2 mg iv dose 6 hours after
first dose if needed. Maximum dose, 4 mg in 24 hours. NO MORE colchicine
should be given by ANY route for 7 days after maximum iv dose is
given]
[Adverse Reactions:
Nausea, vomiting, or diarrhea are typical manifestations of GI toxicity and
are frequently dose related.
Dermatitis, Urticaria, Alopecia, Purpura
Bone marrow supression can be life threatening if maximum doses are exceeded.
Myopathy and neuropathy can occur at any dose.
Dose must be modified according to renal function to avoid dose-related
toxicity.
Avoid use in patients undergoing dialysis patients since dialysis does not
remove the drug.
Use in elderly persons may not be advisable.]
-
Corticosteroid
PO: Prednisone 40-60 mg/d PO (in divided doses) until
symptoms begin to subside, then rapidly taper over several days
.
IM injection: Triamcinolone acetonide (Kenalog), 60 mg.
Methylprednisolone (DepoMedrol), 40-80 mg. May repeat in 24 hours if
necessary.
Intraarticular injections: Triamcinolone hexacetonide (Aristospan
Intralesional), 40 mg for large joints, 5-20 mg for small joints.
Methylprednisolone acetate (DepoMedrol), 40-80 mg for large joints, 20-40
mg for small joints.
Betamethasone acetate (Celestone), 1.5-6 mg
-
ACTH 40 u IM every 8-24 hours as needed
-
Triamcinolone acetonide (Kenalog/Aristocort) 60 mg IM, or
Prednisone 30-50 mg PO daily, tapering over 7 days.
Prophylaxis against acute attacks ("Make the matches damp")
-
Colchicine 0.6 mg 1-3x/day. (Generally after starting urate-lowering
drug & urate level has been controlled, & no acute attack for 1-3
months)
-
Indomethacin 50 mg bid or Ibuprofen 400-800 mg tid with meals.
-
Urate-lowering agents ("Remove the matches from the body")
Allopurinol /Zyloprim 300 mg/day PO usually (for hyperuricemia
associated with overproduction, urin. uric acid excretion>700 mg/24h,
nephrolithiasis, prophylaxis before chemotherapy,)
-
Uricosuric agents:
(for under-excretion of uric acid <700 mg/24h, GFR >50 mL/min, no acute
gout, no kidney stone history)
Probenecid /Benemid 500-1000 mg bid PO;
- 0.5 to 2 g/d, divided bid and dose adjusted until serum uric
acid level normalizes.
- Twice daily dosing required. Not effective in patients with
renal insufficiency.
Sulfinpyrazone/Anturane 50-200 mg bid PO;
- Usual dose, 300-400 mg/d, but may increase up to 800 mg/d if patient does
not respond to maintenance doses.
- As effective as probenecid and well tolerated. Monitoring of renal function
is advisable.
Benzbromarone 25-120 mg daily.
Recognize that optimal management of acute gout
requires control of inflammation as well as pain relief.
-
Consider treatment with nonsteroidal antiinflammatory drugs (NSAIDs),
corticosteroids, colchicine, and analgesics, alone or in combination, to
manage acute gout.
-
Use NSAIDs or narcotics (or both) for adequate analgesia.
-
Note that the choice of agents for acute gout depends largely on patient
characteristics and especially on the presence or absence of concomitant
disease.
-
Be aware that traditional NSAIDs have usually been the first-line therapy
owing to their combined analgesic and anti-inflammatory effects; newer
cyclooxygenase-2-selective NSAIDs have similar efficacy but have not been
widely studied as treatment of acute gout.
-
Use corticosteroids when NSAIDs are deemed unsafe in elderly persons, patients
with renal insufficiency or active GI ulceration, and those receiving concurrent
anticoagulation or other interacting drugs, or after surgery.
-
Use a local steroid injection of a single involved joint (e.g., knee, ankle,
elbow, or wrist) if other interventions have been ineffective or are relatively
contraindicated.
-
Do not give NSAIDs to patients with renal insufficiency or elderly persons
with other risk factors for NSAID gastropathy.
-
Do not give full dose colchicine to patients with renal insufficiency.
-
Be aware that patients with peptic ulcer disease may not tolerate NSAIDs.
-
Recognize that patients with diabetes may develop increasing hyperglycemia
while taking corticosteroids.
In patients with recurrent acute attacks or more
than 1 or 2 acute attacks in 1 year:
-
Administer uric acid-lowering agents to achieve a serum uric acid level <5
mg/dL, if possible
-
Recognize that therapy may be required lifelong
-
Consider 24-hour urinalysis quantitating uric acid secretion and creatinine
to identify whether the patient is an “undersecretor” of uric acid
(<600 mg/d while consuming a low-purine diet)
-
Use uricosuric agents or xanthine oxidase inhibitors (or both) to decrease
uric acid levels; if urate oxidase becomes available in the United States,
it may be an alternative method of decreasing urate levels in patients who
are intolerant of other therapies
-
Do not initiate treatment with any uric acid-lowering
agents during an acute gout attack; wait for 1 or 2 weeks for the attack
to completely resolve
-
Consider using colchicine to prevent acute gout attacks when initiating uric
acid-lowering therapy
When initiating treatment with allopurinol, a xanthine
oxidase inhibitor:
-
Begin with half of the projected dose and increase to the full projected
dose in 2 to 3 weeks to minimize exacerbations
-
Use a lower projected dose in patients with renal
insufficiency
-
Caution patients to immediately report side effects, such as rash
-
Consider initiating treatment with uricosuric agents in patients who are
probably secreting <600 mg of uric acid daily while consuming a low-purine
diet
-
Note that uricosurics are generally not effective
in patients with renal insufficiency and a creatinine clearance <40 mL/min,
necessitating use of allopurinol
-
Recognize that once-daily allopurinol may be more convenient for patients
and increase adherence to therapy
-
Do not use uricosuric agents in patients with nephrolithiasis
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