Gout

Question 1

Hyperuricaemia

Causes, drug interactions included

Answer 1

Abnormality in uric acid metabolism - uric crystals in joints
Due to impaired renal function
Drug interactions - thiazide diuretics, low dose aspirin

Question 2

Dietary Purines

Answer 2

High purine foods - alcohol, anchovies, sardines, herring, mussels, codfish, scallops, trout, haddock, bacon, turkey, veal, venison and organ meats
Moderate purine foods - beef, chicken, duck, pork, ham, crab, lobsters, oysters and shrimp

Question 3

Acute Attack Treatment: NSAIDs

Safest option, what is not given, how long

Answer 3

Naproxen - safest for CVD
Others - Diclofenac, Indometacin, Ketoprofen, Sulindac, Etoricoxib
Given with PPI
Aspirin - not given as it causes uric acid retention
Only for short term - 7-14 days

Question 4

Acute Attack Treatment: Colchicine

When to start, S/E, reduce dose for, can be given with

Answer 4

Specific treatment
Slow onset of action and high incidence of S/E
Should be started ASAP after symptoms appear - only repeat in acute attacks
Can be given alongside anticoagulants
Pain relief - 18 hrs after, inflammation subsides after 48hrs
S/E - N+V and abdominal pain
Reduce dose - elderly and renal insufficiency

Question 5

Acute Attack Treatment: Corticosteroids

Only given if

Answer 5

Intra-articular corticosteroids e.g. Methylprednisolone - only if 1 or a few joints are affected

Question 6

Acute Attack Treatment: Canakinumab

Only given when

Answer 6

IL-1 inhibitor
Only given if NSAID, Colchicine and Corticosteroid are unsuitable or ineffective

Question 7

Acute Attacks Prevention: Lifestyle Modifications

Answer 7

Weight reduction
Decrease alcohol consumption
Reduce dietary purine intake
Increasing water intake - to dilute uric acid and prevent kidney stones production
Medicines adjustment - diuretics, immunosuppresants, chemotherapy, aspirin, TB meds e.g. ethambutol and pyrazinamide

Question 8

Long term Management: Urate Lowering Therapies (ULTs)

When to start, managing an acute attack

Answer 8

Not given during an acute attack - give 2-4 weeks after an attack has settled
Inititation may precipitate an acute attack - give NSAID or colchicine to manage (prophylaxis dose e.g. Colchicine 500mcg BD, NSAID 75mg)

Question 9

Long term Management: Allopurinol

MOA, initial dose, consideration, S/Es

Answer 9

Inhibits formation of uric acid
Initial - 100mg daily after food then adjust according to uric acid concentration
Useful in patients with renal impairment or urate stones - dosage should be reduce to prevent accumulation
Ensure adequate fluid intake
S/E - rash (most common), exfoliative dermatitis (extreme)

Question 10

Long term Managemet: Febuxostat

MOA, contraindications, S/E, dose

Answer 10

Decreases serum uric acid concentration
S/E - diarrhoea, nausea, headache, LFTs abnormalities, rash
Not recommended for ischaemic heart disease or congestive heart failure
Recommended dose - 80mg OD
Given if Allopurinol is contraindicated or not tolerated

Question 11

Uricosurics

MOA, considerations, contraindications, meds

Answer 11

Increases uric acid excretion
Given if patient is intolerant of Allopurinol
Although relatively ineffective with poor renal function - contraindicated
Should be given with prophylactic therapy for acute attacks
Ensure adequate fluid intake
Sulphinpyrazone
Benzbromarone
Rasburicase - in chemo