[Allred Charles]the GOUT
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Transcript of [Allred Charles]the GOUT
The GOUTC. T. Allred, M.D.
2/4/10
Clinical Syndromes
• Acute gouty arthritis – the first episode.
– Usually preceded by hyperuricemia for years
– First MTP joint (podagra - 50%), other foot joint, ankle or knee in 30% of first time cases.
– Usually monoarticular (80%) with first case. Can be polyarticular in recurrent cases.
– First episode is frequently excruciating building up over several hours, to the point a person cannot stand to have a sheet touching.
Acute gout
• The redness is
sometimes shiny,
sometimes dull.
• Warm.
• Very tender to touch.
Acute gout
• Other common areas
of affliction.
Acute gout
Acute gout
Gout risk factors
• “Classic” – an
obese,hypertensive
man, age 30 to 50,
frequent imbiber of
alcohol (especially
beer)
Gout risk factors
• Women = men over age
65.
• Trauma to joint.
• Hospitalization for
anything. (20% of gout
sufferers will have an
attack in hospital.)
• Diet high in meat and
fish.
• Chronic renal
insufficiency.
Gout risk factors
• Medications:
– Diuretics – thiazides and furosamide.
– Nicotinic acid (niacin).
– Aspirin.
– Cyclosporine (gengraf, neoral).
– Ehtambutol.
– Pyrazinamide.
– Levodopa.
Gout Dx.
• Pt. may be febrile.
• WBC may be elevated.
• ESR 50 to 80 range.
• CRP elevated.
• Uric acid may be normal 20 to 40% of the
time at the time of the attack.
• Definitive dx. – intracellular monosodium
urate crystals in synovial fluid.
Gout – presumtive dx. without arthrocentesis
• A classic history of one or more episodes
on monoarticular arthritis followed by
periods completely free of symptoms.
• Max. inflamation within 24 hours.
• Rapid resolution with colchicine tx.
• Podagra.
• Hyperuricemia.
• Subcortical bone cysts apparent on x ray.
Differential dx.
• Septic joint.
• Pseudogout – calcium pyrophosphate
dihydrate crystal arthropathy. Usually
knee or wrist.
• Reactive arthritis.
• For polyarticular arthritis, RA, SLE,
psoriatic, etc.
• Always consider the background info.
X ray in gout
Treatment of acute gout
• Colchicine 1.2 mg stat, then .6 mg q 2 hours until relief or 6 mg.
– Problem is virtually everyone gets N/V and/or diarrhea after about 3 doses.
– If it works, suggestive but not diagnostic of gout.
– Other serious problems – renal and hepatic injury, CNS dysfunction, neuromyopathy especially in elderly or those with decreased renal or liver function.
Treatment of acute gout
• NSAIDs:
– Indocin 50 mg q 6 to 8 hours x 24 to 48 hours, then decrease to 25 tid x 3 to 5 days.
• Works well. Highest risk of GI bleed of NSAIDs.
– Ibuprofen 800 mg q 8 hours x 24 to 48 hours, then 400 to 600 tid x 3 to 5 days.
– Naprosyn 750 mg first dose, then 250 tid x 2 days, then bid x 3 days.
– Almost any other NSAID will work if high enough doses. Start early!!!!!
Treatment of acute gout
• NSAIDs
– The usual problem is renal insufficiency,
hypertension, heart failure, ulcers or bleeding
that keeps one from utilizing.
– Again start early.
Treatment of acute gout
• Corticosteroids
– Prednisone 40 to 60 per day x 2 to 3 days,
then taper over 3 to 7 days.
– Triamcinolone 40 to 60 mg IM x 1.
– Intra-articular injection, dose dependent on
the joint.
• Have to make sure you have the diagnosis before
injecting.
Hyperuricemia
• Treat when gout 2 to 3 x per year.
• Asymptomatic and uric acid > 12.
• Tophaceous gout.
• Gout and any history of kidney stones.
• Gout with renal insufficiency.
• Acute uric acid nephropathy.
Hyperuricemia tx.
• Most patients are underexcreters – 85%.
• Those pts could be treated with uricosuric drugs – probenecid and sulfinpyrazone.– Probenecid is well tolerated.
• Can’t use if kidney stones, renal insufficiency.
• Some drug interactions.
• Need to produce at least 1500 ml urine per day.
• Start at 250 mg bid increasing to 1000 mg 2 to 3 x/d over several weeks.
• Target is < 6 uric acid level.
• Need a 24 hour urine for uric acid to demonstrate not an overproducer.
Hyperuricemia tx.
• Xanthine oxidase inhibitors:– Allopurinol
• Start at 100 mg/d for 2 weeks and increase by 100 mg bid every two weeks until at 300 mg/d.
• Increase dose thereafter to achieve uric acid < 6.
• Adjust dose for creatine clearance less than 80 ml/mim.
• Drug interactions – cyclophosphamide, azathioprine, mercaptopurine. Increase incidence of rash with ampicillin.
• Problems: 3 to 5% develop rash, leukopenia, thrombocytopenia, diarrhea, and drug fever.
– 1 in 1000 will develop allopurinol hypersensitivity syndrome –rash, fever, hepatitis, eosinophilia, acute renal failure with up to 25% mortality.
Hyperuricemia tx.
• Xanthine oxidase inhibitors:
– Febuxostat (Urolic)
• A new drug.
• Same drug interactions.
• Expensive compared to allopurinol.
• Start at 40 mg/d, increase to 80 if not at goal in 2
to 4 weeks.
• Monitor LFTs “periodically.”
• Increased incidence of CV events compared to
allopurinol.
Hyperuricemia tx.
• Colchicine prophylaxis
– .6 mg 1 to 2 x/d depending on creatine
clearance. Don’t use if less than 10 and
take q 2-3 days if 10 to 20.
– Use the first 3 to 6 months when instituting
uric acid lowering therapy.
• Rasburicase (elitek)
– IV med to be used to prevent tumor lysis
syndrome.