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Gout - all you need for primary care
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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.

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

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