gout Flashcards
(14 cards)
Definition gout
Chronic disease that involves deposition of monosodium urate crystals in the body- primarily in joints, soft tissues and kidneys
Clin f of gout
Joint pain and swelling = acute attack, chronic gouty arthritis -
– during an acute attack may present with fever, malaise, leukocytosis, elevated inflammatory markers.
Kidney- nephrolithiasis, chronic urate nephropathy –>CKD
Risk factors for developing gout
strong family history of gout
drugs that inhibit renal excretion of uric acid (eg thiazide diuretics, loop diuretics, ciclosporin)
consumption of purine-rich foods
consumption of alcohol
consumption of fructose-sweetened drinks
disorders involving high cell turnover (eg haematological malignancies, severe psoriasis)
obesity
hypertension
chronic kidney disease
dyslipidaemia
type 2 diabetes
a catabolic state
dehydration.
clin f of acute gout
> monoarticular - first MTP jt - painful, red swollen
Females- firs attack can be polyarticular, typically in hands and with gouty tophi
clin f of chronic gout
May by oligoarticular or polyarticular - can mimic rheumatoid arthritis and psoritatic arthrits
GOuty tophi - in elbows, knees and peripheral joints
dx of gout
Definitive - monosodium urate crystals in synovial fluid or tophi
Also undertake MCS of synovial fluid to r/o infection
Serum uric acid concentration - presence of hyperuricemia is insufficient to dx gout and can be normal in puts with acute gout
If synovial fluid analysis is not feasible (ie the joint is difficult to aspirate [eg the big toe]), a clinical diagnosis of gout is supported by the following features:
monoarticular involvement of the foot or ankle (especially the first metatarsophalangeal [MTP] joint)
previous similar acute arthritis episodes
rapid onset of severe pain and swelling (reaching a peak in the intensity of pain and swelling within 24 hours)
erythema
tophi
strong family history of gout
cardiovascular disease and hyperuricaemia in males or postmenopausal females.
Management points in gout
Starting drug therapy for acute gout
Staring lifelong urate lowering therapy
Adressing modifiable risk factors
Considering alternate medications if a current drug is contributing to gout
Management of acute gout
Corticosteroids - have lower incidence of adverse effects than PO NSADIS. –> for rapid symptom relief - can be injected in up to 2 joints or taken PO
PO NSAIDS- higher adverse effects than CS
PO Colchicine - small therapeutic window, risk of toxicity, adverse effects at higher doses. - Considered for patients who have previously used it to successfully manage an acute flare of gout - unlikely to be effective if not started within 24hours of an attack
Management of chronic gout
Urate lowering therapy: dissolves existing crystals, reduces frequency and severity of attacks, resolves tophi.
Titrated in a treat to target approach.
- 1. Allopurinol - avoid combination with azathioprine or mercaptopurine. SFX: bone marrow toxicity, skin rash , allopurinol HSN syndrome
- 2. Febuxostat (CI: CV disease) or probenecid (CI:hepatic/renal impairment)
Can be started alongside acute attacks - starting or increasing urate therapy is associated with high risk of gout flare. so also start flare prophylaxis: Colchicine OD 500microg
In which patients with gout, would starting urate lowering therapy be more important in:
one or more subcutaneous tophi
evidence of radiographic damage
two or more flares annually
patients who have experienced more than one flare after a first gout attack and have a high serum urate with concomitant moderate to severe kidney impairment or kidney stones.
target serum uric acid concentrations in gout
People with tophi, chronic arthropathy or frequent attacks - Less than 0.30 mmol/L (5 mg/dL) initially until total crystal dissolution and resolution of gout, then less than 0.36mmol/L (6 mg/dL)
People with nontophaceous gout - Less than 0.36mmol/L (6 mg/dL)
Which medications should you avoid combining/ prescribing in combination with chronic gout meds
Azathioprine or mercaptopurine
What medication is recommeneded for flare prophylaxis when starting or changing the dose of urate lowering therapy
- Colchicine OD 500microg- continued until no further attacks and target serum uric acid conc has been achieved
Can consider NSAIDS and low dose PO CS
Next step: uric acid concentration not lowering in patient taking allopurinol
Check drug adherence before altering therapy
