Gout - all you need for primary care

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A case by case presentation of Gout cases. For Health care professionals but all welcome.

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  • 47150 MALE HEALTH PROFESSIONALS AGED 40-75 YRS. TWICE ANNUAL QUESTIONNAIRES RE DIET AND ALCOHOL INTAKE. PREVIOUS GOUT EXCLUDED. 1 DRINK A DAY 1.29, 2 DRINKS 1.49 , 3 A DAY 1.96, > 4 DAY 2.53. NO URATE LEVELS MEASURED. STUDY WITH 4 INDIVIDUALS. BEER, VODKA VODKA AND ORANGE AND ORANGE SIGNIFICANT FOR BEER
  • Gout - all you need for primary care

    1. 1. Dr. Ronan Kavanagh Consultant Rheumatologist Galway Clinic
    2. 2. <ul><li>Severe pain big toe 3 days </li></ul><ul><li>Just returned from golfing trip Thailand </li></ul><ul><ul><li>PMHx: Hypertension </li></ul></ul><ul><ul><li>Thiazide diuretic </li></ul></ul>A Medical Colleague in his 50’s
    3. 3. <ul><li>Investigations </li></ul><ul><ul><li>WCC 13 </li></ul></ul><ul><ul><li>ESR 50, CRP 60 </li></ul></ul><ul><ul><li>Uric acid 325 (normal) </li></ul></ul>
    4. 4. Uric acid levels normal in 30-50% acute attacks <ul><li>What about the normal uric acid? </li></ul>
    5. 5. <ul><li>IF URIC ACID NORMAL, REPEAT 2 WEEKS AFTER AN ATTACK </li></ul>
    6. 6. What about this?
    7. 7. <ul><li>Treatment? </li></ul>
    8. 8. Treatment of Acute Gout <ul><li>Treat early </li></ul><ul><li>Encourage oral intake fluids </li></ul><ul><li>Full dose NSAID </li></ul><ul><li>Prednisolone 30-40mg til attack settles then rapid taper </li></ul><ul><li>Colchicine: 1mg stat and 500mcg 6hrly til settles </li></ul>
    9. 9. Joint aspiration and injection It is possible to find crystals in asymptomatic joints between attacks
    10. 10. Diagnosis <ul><li>Uric acid may be normal (check after 2 weeks) </li></ul><ul><li>Don’t treat hyperuricaemia </li></ul><ul><li>Aspirate joints for definitive diagnosis </li></ul><ul><li>Can aspirate joint after event </li></ul>
    11. 11. Any other tests?
    12. 12. <ul><li>Renal function </li></ul><ul><li>Weight measurement </li></ul><ul><li>Don’t forget the BP! </li></ul><ul><li>Fasting lipids </li></ul><ul><ul><li>(Hypertriglyceridaemia) </li></ul></ul><ul><li>Fasting glucose / dipstick urine </li></ul><ul><li>Uric acid excretion? </li></ul>
    13. 13. 6 weeks later <ul><li>The patient returns and reports four additional acute gouty attacks that responded to colchicine </li></ul><ul><li>On Allopurinol 300mg once daily </li></ul><ul><li>‘Worse’ since starting </li></ul><ul><li>BP is 130/80 with lisinopril. </li></ul>
    14. 14. COMMON REASONS FOR LACK RESPONSE <ul><li>Starting Allopurinol during an attack </li></ul><ul><li>No prophylaxis </li></ul><ul><li>Stopping allopurinol during an attack </li></ul><ul><li>Dose of allopurinol too low </li></ul>
    15. 15. <ul><li>URIC ACID 390 (NORMAL RANGE < 430) </li></ul>
    16. 16. TARGET URIC ACID <ul><li>EULAR suggest < 360 umol/l 1 </li></ul><ul><li>British Society for Rheumatology < 300 umol/l 2 </li></ul><ul><li>(‘normal’ lab range <430) </li></ul>
    17. 17.
    18. 18. Allopurinol
    19. 19. MEDICAL MANAGEMENT OF CHRONIC GOUT Start allopurinol gently (ideally not during acute attack) 100mg od after a week to 300mg od Co-prescribe prophylaxis for 1 st 6 weeks Colchicine 500mcg od Low dose NSAID (avoid in this patient) Low dose steroids (Pred 5-7.5mg daily) Check Urate after a month
    20. 20. <ul><li>Most require 300MG – 500mg </li></ul><ul><li>Doses of up to 800MG may be required </li></ul><ul><li>Increase monthly dose depending on uric acid levels </li></ul><ul><li>Typically 100MG – 300MG – 500MG – 600MG – 800MG </li></ul><ul><li>Keep uric acid < 300 </li></ul>ALLOPURINOL
    21. 21. Allopurinol sensitivity <ul><li>Rare </li></ul><ul><li>Severe reactions < 0.1% </li></ul><ul><li>More common in patients with renal impairment* </li></ul><ul><li>More common higher doses </li></ul><ul><li>Skin rashes 3% </li></ul><ul><li>Mild LFT abn. </li></ul><ul><li>Stop if rash occurs </li></ul><ul><li>Avoid with Azathioprine and mercaptopurine </li></ul>*Arthritis Rheumatism 2009, S60; 761
    22. 22. Treatment adherence rates after 1 year Pharmacotherapy. 2008;28(4):437-443
    23. 23. What about alcohol? <ul><li>Alcohol reduces renal urate excretion </li></ul><ul><li>Increasing hepatic production of uric acid </li></ul><ul><li>Dehydration and acidosis </li></ul><ul><li>Reduces metabolism of allopurinol to active metabolite </li></ul><ul><li>Beer contains guanosine which is converted to urate </li></ul>
    24. 24. I suppose I’ll have to give up the drink then? O.R. = 2.5 O.R. = 1 O.R. = 1.6 Choi HK et al. Lancet 2004; 363: 1277–81 x2 x2 x2
    25. 25.
    26. 26. I might as well drink wine....... O.R. = 2.5 O.R. = 1 O.R. = 1.85 X2 X2 X2
    27. 27. Advise to drinkers <ul><li>Don’t drink to excess if your father had gout </li></ul><ul><li>If you drink to excess don’t forget to eat </li></ul><ul><li>If you do eat, rethink your diet </li></ul><ul><li>If you are on allopurinol watch yoour urate when you drink! </li></ul>
    28. 28.
    29. 29. Low purine diets
    30. 30. What about diet? <ul><li>Dietary trends increasing prevalence of Gout </li></ul><ul><ul><li>Associated with Obesity and Insulin resistance </li></ul></ul><ul><li>Low purine diet </li></ul><ul><ul><li>Unpalatable </li></ul></ul><ul><ul><li>Small reduction uric acid (max 10%) </li></ul></ul><ul><li>Current diet focus on: </li></ul><ul><ul><li>Wt management </li></ul></ul><ul><ul><li>Moderation of meat and seafood </li></ul></ul><ul><ul><li>Restriction non complex carbohydrates </li></ul></ul>
    31. 31. Diet continued <ul><li>Regular intake of low fat dairy products reduces attacks </li></ul><ul><li>Drinking 5-8 glasses water in 24hrs before attack reduces attacks by 40% </li></ul><ul><li>Not as important if gout well controlled with meds </li></ul>
    32. 32. A word about tophi
    33. 33.
    34. 34.
    35. 35.
    36. 36. Gout and renal impairment <ul><li>Uric acid 640 </li></ul><ul><li>Creatinine 150 </li></ul><ul><li>eGFR = 30mls/min </li></ul><ul><li>47% of patients with gout in general practice have eGFR < 60 mls /min </li></ul>
    37. 37. Gout in renal failure <ul><li>Need to reduce dose of Allopurinol in renal failure </li></ul><ul><li>Reduced dose means reduced efficacy </li></ul><ul><li>Risk of Allopurinol toxicity higher in pts with renal failure (still rare) </li></ul>
    38. 38.
    39. 39. Asymptomatic hyperuricaemia
    40. 40. Do we need to treat hyperuricaemia? <ul><li>Strongest risk factor for gout but </li></ul><ul><ul><li>0.5% yearly inc. if uric acid 420-530 μmol/l </li></ul></ul><ul><ul><li>4.5% if uric acid > 540 μmol/l </li></ul></ul><ul><li>Double risk of uric acid renal stones </li></ul><ul><li>Renal damage? </li></ul><ul><li>Hypertension? </li></ul><ul><li>Cerebrovascular disease? </li></ul>
    41. 41. “ Evidence does not yet support the general treatment of asymptomatic hyperuricaemia to reduce cardiovascular risk” NEJM 2008;359:11811-21
    42. 42. Alternatives to allopurinol <ul><li>Probenecid 250mg bd increasing to 1g tds </li></ul><ul><ul><li>Less effective if renal impairment </li></ul></ul><ul><li>Losartan </li></ul><ul><li>Fenofibrate (Lipantil) </li></ul><ul><li>Vitamin C </li></ul>
    43. 43. Uricase
    44. 45.
    45. 46.
    46. 47.
    47. 48.
    48. 49.
    49. 50.
    50. 51. Take home points <ul><li>Uric acid may be normal (check after 2 weeks) </li></ul><ul><li>Check Uric acid after a month on treatment </li></ul><ul><li>Aim for Urate < 300 with treatment </li></ul><ul><li>Many patients need more than 300mg allopurinol </li></ul><ul><li>Don’t start Allopurinol during an attack </li></ul><ul><li>Don’t stop Allopurinol during an attack </li></ul><ul><li>Co-prescribe NSAID / low dose colchicine for 1 st 6 weeks </li></ul><ul><li>Look for metabolic syndrome </li></ul>
    51. 52. Take home points <ul><li>Consider reducing dose allopurinol in renal impairment </li></ul><ul><li>Consider Febuxostat in allopurinol sensitivity </li></ul><ul><li>80mg starting dose increasing to 120mg if necessary </li></ul>
    52. 53. Musicians clinic
    53. 54. ‘ Keeping the show on the road’ Musicians Health Conference 2012
    54. 55. Saturday October 13th 2012 Radisson Hotel Galway
    55. 56. Cheers

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