Tophaceous Gout
Common Sites
Base of fingers Forearm knees, wrists, hands
Colchicine Considerations
C/I: Concomitant use of a P-gp or strong CYP3A4 inhibitor in presence of renal/hepati impairment AE: N/V/D, AST/ALT Incr, Mointor: CBC, Renal/hepatic function tests
COX-2 Selective Inhibitor
Celecoxib(Celebrex): 800 mg x1; then 400mg on day 1; then 400mg BID for 1 week Evidence B: Risk/benefit unclear Expensive, Incr risk Ischemid CVD/Heart Failure
Tophi
Urate Deposits - late complication of hyperuricemia
Lifestyle Recommendations
Weight Loss Exercise Smoking Cess Hydration Healthy diet ( Ovoid organ meats, HFCS, Alcohol overuse)
Management of Acute Attack: Monotherapy
1st line: NSAID/COX-2 Inhibitor, Colchicine, or systemic Coricoid Selection based on: 1. Pts Preference 2. Prior Response if prvs gt rspns 3. Co-morbidities 4.Cochine NOT selected if colchicine tx in last 14 days
Febuxostat
AE: Rash, N/D, arthalgias Monitor: LFT @ baseline then period, SUA levels (2wks after titration), S/se hypersentivity
Diagnosis(European )
Aspiration of affected synovial joint -radiographs NOT used
Allopurinol Reactions
DI: Amp Incr rash Decr warfarin metabolism Adverse Rxn: Skin rash, N/D, Incr LFT Monitor: CBC, SUA 2-5 weks then 6 months after titration Hypersense RF: Thiazide use and renal faulire - Consider HLA-B5801 genetic testing in high risk patients
NSAID Consideration
GI Effects: -BBW: Incr risk of GI irritation, ulceration, bleeding Cardio effects: -BBW: Incr risk of fatal MI/strok -Incr BP Renal Effects: - Decr renal blood flow/function - Incr fluid retention(avoid in CHF) Hematologic Effects: - Antiplatelet effects, avoid warfarin
Urate- Lowering Therapy (ULT)
Indicated for patients with an established diagnosis of gouty arthritis AND - Tophus or tophi -Frequent(>2 attacks/yr) AGA 1st Line: Xanthine Oxidase Inhibitors (XOI)- Allopurinol Monitor: Every 2-5 weeks during ULT Titration. Once @ target SUA: Every 6 months
Corticoid injection
Intra-Articular: 1-2 Large Joints - Dose depends on joints involved Large joints- 20-80mg Med - 10-40 mg sm- 4-10 mg
Pegloticase
Last Line therapy Dose 8mg IV every 2wks expensive
Other Uricosuric agents
Losartan or fenofibrate Can be used with XOI therapy
Probenecid
MOA Uriosuric agent that inhibits uric acid reabsorption and increases exretion Not 1st line Dose: 250 mg BID 1/week avoid CrCl <30 C/I: Alrgy, <2 y/o, aspirin
Corticosteroid(oral)
MOA: Suppresses inflammation by mimicking the action of cortisol in the body Oral Dosing: - Prednisone 0.5mg/kg/day - 5-10 days at full dose then stop OR - 2-5 days at full dose then taper 7-10 days then stop - Methylprednisolone Dose Pack
Colchicine(Colcrys)
MOA: Thought to inhibit neutrophil phagocytic activity by preventing microtubule formation Use w/in 36 hrs of attack Loading Dose- 1.2mg. Followed by 0.6mg 1 hr later. Can be followed by 0.6mg 1-2x/day 12 hrs later until attack resolves Tx dosing: DOES NOT REQUIRE RENAL ADJ - Severe impairment (CrCl <30 ml/min) - Do not repeat tx for 14 days
NSAID Dosing
Naproxen: 750mg; then 250 mg Q8H ER: 1000-15000 mg 1x/day Indomethacin: 50mg TID Sulindac: 200mg BID Ibuprofen: 800mg Q6H Estimated tx duration: -1-2 days if tx intitiated quickly -up to 7-10 days if tx delayed
Corticosteroids AE
P: Psychiatric- mood changes R: Round Face E: Eyes (glaucoma, cataracts) D: Diabetes (Incr blood glucose) N: Neutrophilia (Common SE) I: Immunosuppression, Insomnia S: Stomach (GI Upset, ulcer) O: Osteoporosis, obesity N: NA/H2O Retention E: Electrolyte (Incr Na, Decr K+)
Treament guidelines
Part 1: systemic Non-pharm and Pharm approaches to hyperuricemia Part2: Therapy and anti-infl prophylaxis of acute gouty arthritis
Combination Therapy
Sever Gout Attack: >VAS w/>1 large joint OR Inadequate rspns Colchicine + NSAID Colchicine + PO Steroid
Complications
Soft Tissue Damage Deformity Joint destruction nerve compression
Allopurinol Dose
Starting Dose: - 100 mg/day -50 mg/day in CKD stage 4/5 (CrCl <30mL/min) Titrate to target SUA <6 mg/dL Max Dose: 800mg/day Split daily dose when >300mg/day