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.