Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
REVISITING GOUT
Updating the Recommendations
Sidney Erwin T. Manahan, MD FPCP FPRA
21st PRA Annual Meeting - PRECONVENTION...
DISCLOSURES
• Module developer for Pfizer (Celebrex)
• Member, Speakers’ Bureau for Pfizer (Celebrex, Lyrica)
• Honoraria ...
Disease Manifestations
Natural Course of Disease
0 10 20 30
Duration of Hyperuricemia (Years)
7
14
LevelofHyperuricemia(mg/dl)
Asymptomatic
ACUTE...
OBJECTIVE
Provide updates to recommendations made by the
2008 Philippine Clinical Practice Guidelines on the
Management of...
Gout Classification Criteria
Criteria Categories Score
Clinical Pattern of Involvement Ankle / midfoot 1
MTP1 2
No of epis...
Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
INTERVAL
GOUT
CHRONIC
GOUT
Terminate
the Attack
Prevent recurrent attac...
         
         
         
         
         
         
 ...
         
         
         
         
         
         
 ...
         
         
         
         
         
         
 ...
Asymptomatic
Hyperuricemia
>7mg/dl (M)
>6mg/dl (F)
Hypertension
CV Disease
Stroke
Renal Disease
Metabolic
Syndrome
CAUSE
R...
Asymptomatic Hyperuricemia
Philippine
CPG
ACR
2012
3E
Initiative
NO RECOMMENDATION due to paucity of
prospective trials
Ph...
Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
Terminate
the Attack
Prevent the
1st Attack
Philippine
CPG
ACR
2012
3E
Initiative
Colchicine
NSAIDs/
COXIBs
Steroids
Colchicine
NSAIDs/
COXIBs
Steroids
Colchicine
NSA...
Recommended Drugs in Acute Gout
Colchicine
NSAIDs/
COXIBs
Steroids
1mg then 0.5mg TID
12h later
Full anti-
inflammatory do...
CAUTION!
CONDITIONS Colchicine
NSAIDs/
COXIBs
Steroids
Chronic renal disease X X
Heart failure X
Peptic ulcer disease X X
...
Pain VAS <6/10 OR
Few small joints OR
1 -2 large joints
Pain VAS >6/10 OR
Polyarthritis OR
1 -2 large joints
OPTIONS
• Col...
Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
INTERVAL
GOUT
CHRONIC
GOUT
Terminate
the Attack
Prevent recurrent attac...
Philippine
CPG
ACR
2012
3E
Initiative
Colchicine Colchicine
NSAIDs/
COXIBs
Steroids
Prophylaxis Duration
Colchicine
NSAIDs...
WHEN TO START
URATE-LOWERING THERAPY
Philippine
CPG
ACR
2012
3E
Initiative
COULD be started during an acute gout attack
pr...
INDICATIONS
for Urate Lowering Therapy
• At least 2 flares/year
• Presence of tophi
• Radiographic changes of
arthropathy
...
Philippine
CPG
ACR
2012
3E
Initiative
<6mg/dl
Reduce attacks
Prevent tophi
Target Serum Uric Acid
<6mg/dl
For most
patient...
Philippine
CPG
ACR
2012
3E
Initiative
LONG
TERM
Duration of Urate Lowering Therapy
LONG
TERM
LIFE
LONG
• Treat hyperuricem...
Philippine
CPG
ACR
2012
3E
Initiative
Allopurinol
Choice of Urate Lowering Therapy
Allopurinol
Febuxostat
Losartan,
Fenofi...
Start
PRIMARY DRUG
Is drug
TOLERATED?
Was target SUA
ACHIEVED?
MONITOR
Shift to other drug
Titrate up
SUA, creatinine,
LFT...
Start
PRIMARY DRUG
Is drug
TOLERATED?
Was target SUA
ACHIEVED?
MONITOR
Shift to other drug
Titrate up
SUA, creatinine,
LFT...
Which is BETTER?
100mg
200mg
300mg
400mg
500mg
600mg
700mg
800mg
40mg
80mg
120mg
240mg
Tayar JH, et al. Febuxostat for tre...
Lifestyle Changes in Gout
Exercise /
Weight
management
Adequate
Hydration
Smoking
Cessation
Diet
Dietary Recommendations Pre 2008
Diet Choices in Gout: MODERATION
AVOID
• Organ/ red meats
• Drinks with fructose
(corn syrup)
• Alcoholic drinks
LIMIT
• S...
Let’s treat Gout
BETTER!
• Identify the stage of disease
• Set goals appropriate for stage
• Give proper advice and treatm...
CALL A FRIEND
Your friendly neighborhood
RHEUMATOLOGIST
• Refractory gout
• Difficulty in achieving target SUA
• Multiple ...
THANK YOU!
Upcoming SlideShare
Loading in …5
×

Revisiting Gout: Guideline Updates PRA 2015

9,399 views

Published on

I was asked by the organizers to review updates on the management of gout. I compared guideline recommendations from the 2008 Philippine CPG to the 2012 ACR Recommendations and the 2014 3E Initiative.

Published in: Health & Medicine
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • The Kidney Disease Solution PDF Download Link  http://scamcb.com/empoweredh/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • The Kidney Disease Solution PDF Download Link ♣♣♣ https://tinyurl.com/yy8pd5uf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Thanks for sharing your presentation Dr. Manahan. May I ask if you have the latest copy of CPG of Gouty Arthritis? Thank you!
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • my email medicalspecialist71@yahoo.com
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Revisiting Gout: Guideline Updates PRA 2015

  1. 1. REVISITING GOUT Updating the Recommendations Sidney Erwin T. Manahan, MD FPCP FPRA 21st PRA Annual Meeting - PRECONVENTION 26 February 2015
  2. 2. DISCLOSURES • Module developer for Pfizer (Celebrex) • Member, Speakers’ Bureau for Pfizer (Celebrex, Lyrica) • Honoraria for talks given on behalf of Ajanta Phils (Atenurix) and Roche (Actemra) • Participated in drug trials as sub-investigator/ co- investigator for Roche, Wyeth, Parexel (Janssen) and Novartis
  3. 3. Disease Manifestations
  4. 4. Natural Course of Disease 0 10 20 30 Duration of Hyperuricemia (Years) 7 14 LevelofHyperuricemia(mg/dl) Asymptomatic ACUTE GOUT INTERVAL GOUT CHRONIC GOUT
  5. 5. OBJECTIVE Provide updates to recommendations made by the 2008 Philippine Clinical Practice Guidelines on the Management of Uncomplicated Gout Philippine CPG ACR 2012 3E Initiative Khanna D, et al. 2012 ACR Guidelines for Management of Gout (2 parts). Arth Care & Res 2012 64 (10): 1431-61. Sivera F, et al. Multinational Evidence-Based Recommendations for the Diagnosis and Management of Gout. Ann Rheum Dis 2014; 73: 328-35. Li Yu J, et al. Philippine Clinical Practice Guidelines on the Medical Management of Uncomplicated Gout. Phil J Int Med 2008.
  6. 6. Gout Classification Criteria Criteria Categories Score Clinical Pattern of Involvement Ankle / midfoot 1 MTP1 2 No of episodes ever One 1 Two 2 Three 3 Time Course One typical 1 Recurrent 2 Clinical Tophus Present 4 Laboratory Serum uric acid 6-8mg/dl 2 8-10mg/dl 3 >10mg/dl 4 Imaging US or DECT Present 4 Xray erosion Present 4
  7. 7. Treatment Objectives Asymptomatic Phase ACUTE GOUT INTERVAL GOUT CHRONIC GOUT Terminate the Attack Prevent recurrent attacks Prevent/reverse complications Prevent the 1st Attack Lower serum uric acid to target
  8. 8.                                                                                                    
  9. 9.                                                                                                    
  10. 10.                                                                                                    
  11. 11. Asymptomatic Hyperuricemia >7mg/dl (M) >6mg/dl (F) Hypertension CV Disease Stroke Renal Disease Metabolic Syndrome CAUSE RESULT ?
  12. 12. Asymptomatic Hyperuricemia Philippine CPG ACR 2012 3E Initiative NO RECOMMENDATION due to paucity of prospective trials Pharmacologic treatment is NOT recommended to prevent gout, renal or cardiovascular disease Do NOT routinely treat with Allopurinol Address conditions associated with hyperuricemia CAVEAT Serum uric acid >11-13mg/dl (Nephrolithiases) Tumor lysis syndrome Prevent CKD Stage 2-3 progression
  13. 13. Treatment Objectives Asymptomatic Phase ACUTE GOUT Terminate the Attack Prevent the 1st Attack
  14. 14. Philippine CPG ACR 2012 3E Initiative Colchicine NSAIDs/ COXIBs Steroids Colchicine NSAIDs/ COXIBs Steroids Colchicine NSAIDs/ COXIBs Steroids Acute Gout Patient Preference  Experience  Comorbid Disease Combination Therapy
  15. 15. Recommended Drugs in Acute Gout Colchicine NSAIDs/ COXIBs Steroids 1mg then 0.5mg TID 12h later Full anti- inflammatory dose Prednisone 1mkd x 2- 5days the taper x7d Prednisone 0.5mkd for 5-10 days Triamcinolone 60mgIM IA Steroids
  16. 16. CAUTION! CONDITIONS Colchicine NSAIDs/ COXIBs Steroids Chronic renal disease X X Heart failure X Peptic ulcer disease X X Anticoagulants X Diabetes mellitus X Infections X Liver disease X X Khanna D, et al. 2012 ACR Guidelines for Management of Gout (2 parts). Arth Care & Res 2012 64 (10): 1431-61.
  17. 17. Pain VAS <6/10 OR Few small joints OR 1 -2 large joints Pain VAS >6/10 OR Polyarthritis OR 1 -2 large joints OPTIONS • Colchicine • NSAIDs / COXIBs • Steroids COMBINATION THERAPY Start treatment w/in 24 HOURS RESPONSE? >20% in 24h OR >50% after 24h
  18. 18. Treatment Objectives Asymptomatic Phase ACUTE GOUT INTERVAL GOUT CHRONIC GOUT Terminate the Attack Prevent recurrent attacks Prevent/reverse complications Prevent the 1st Attack Lower serum uric acid to target
  19. 19. Philippine CPG ACR 2012 3E Initiative Colchicine Colchicine NSAIDs/ COXIBs Steroids Prophylaxis Duration Colchicine NSAIDs/ COXIBs Steroids No Gout Flares • 6 months of target SUA • 3 months of target SUA if without tophi • 6 months of target SUA and resolution of documented tophi
  20. 20. WHEN TO START URATE-LOWERING THERAPY Philippine CPG ACR 2012 3E Initiative COULD be started during an acute gout attack provided effective anti-inflammatory therapy has been instituted NO CONSENSUS. Incidence of flare reflected rate of urate lowering. Start low, go slow in giving urate lowering therapy 10-14 days after flare resolution
  21. 21. INDICATIONS for Urate Lowering Therapy • At least 2 flares/year • Presence of tophi • Radiographic changes of arthropathy • Nephrolithiases • Co-morbid conditions that may complicate treatment of gout (CV disease, CKD)
  22. 22. Philippine CPG ACR 2012 3E Initiative <6mg/dl Reduce attacks Prevent tophi Target Serum Uric Acid <6mg/dl For most patients <6mg/dl Reduce attacks Prevent tophi <5mg/dl If with tophi <5mg/dl Reduce attacks Dissolve tophi Dissolve crystals
  23. 23. Philippine CPG ACR 2012 3E Initiative LONG TERM Duration of Urate Lowering Therapy LONG TERM LIFE LONG • Treat hyperuricemia but not the cause • Discontinuing ULT resulted in recurrence • Depletion of stores after 5 years of target SUA
  24. 24. Philippine CPG ACR 2012 3E Initiative Allopurinol Choice of Urate Lowering Therapy Allopurinol Febuxostat Losartan, Fenofibrate Uricosurics Allopurinol Losartan, Fenofibrate Uricosurics Febuxostat
  25. 25. Start PRIMARY DRUG Is drug TOLERATED? Was target SUA ACHIEVED? MONITOR Shift to other drug Titrate up SUA, creatinine, LFTs ALLOPURINOL 100mg OD* Tolerated Not Achieved Monitor every titration Not tolerated Add losartan or fenofibrate Monitor 3-6 months once stable dose Continue Titrate by 100mg* q 2-4 weeks (max 900mg) Shift to Febuxostat * Dose adjustment in renal impairment (50mg)
  26. 26. Start PRIMARY DRUG Is drug TOLERATED? Was target SUA ACHIEVED? MONITOR Shift to other drug Titrate up SUA, creatinine, LFTs FEBUXOSTAT 40mg OD Tolerated Not Achieved Monitor every titration Not tolerated Add losartan or fenofibrate Monitor 3-6 months once stable dose Continue Titrate by 40mg q 2-4 weeks (max 120mg) Shift to Allopurinol No adjustment in mild moderate renal impairment
  27. 27. Which is BETTER? 100mg 200mg 300mg 400mg 500mg 600mg 700mg 800mg 40mg 80mg 120mg 240mg Tayar JH, et al. Febuxostat for treating chronic gout. Cochrane Database of Systematic Reviews 2012; Issue 11. Art No. CD008653. DOI: 10.1002/14651858.CD008653.pub2 No Statistical difference in Incidence of Gout Flares Rates of adverse events Discontinuation CONVENIENCE FEBUXOSTAT ALLOPURINOL
  28. 28. Lifestyle Changes in Gout Exercise / Weight management Adequate Hydration Smoking Cessation Diet
  29. 29. Dietary Recommendations Pre 2008
  30. 30. Diet Choices in Gout: MODERATION AVOID • Organ/ red meats • Drinks with fructose (corn syrup) • Alcoholic drinks LIMIT • Seafood • Sweetened fruit juices ENCOURAGE • Dairy Products • Vegetables
  31. 31. Let’s treat Gout BETTER! • Identify the stage of disease • Set goals appropriate for stage • Give proper advice and treatment • Educate our patients • Monitor and follow-up regularly
  32. 32. CALL A FRIEND Your friendly neighborhood RHEUMATOLOGIST • Refractory gout • Difficulty in achieving target SUA • Multiple or serious adverse events
  33. 33. THANK YOU!

×