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Gout.pptx
- 2. What is gout? • Chronic progressive inflammatory disease • Persistent hyperuricaemia (serum urate >0.42mmol/L) • Deposition of uric acid crystals in the joint, soft tissues and kidneys • Onset 40-60 years old • Very treatable: adherence to lifelong ULT • Untreated complication: Tophaceous gout
- 3. Symptoms • First attack usually monoarticular (big toe) • Affect other parts of body: ankle, heel, knee, wrist, elbow and fingers • Episodic pain (night) with redness, warmth, swelling and disability • If not treated, usually subside within a week
- 4. Risk factors • Male > Female • Genetical defects in enzyme (HPRT) • Uric acid is formed in liver from dietary & endogenous purines • Purine-rich diet (meat & seafood) • Excessive alcohol consumption (beer & spirits) • Fructose-sweetened drinks • Disorders of high cell turnover (eg severe psoriasis) • Concurrent medication that inhibits excretion of uric acid (eg thiazide) • Recent initiation of urate-lowering therapy (ULT)
- 6. Management of ACUTE gout • Provide symptom relief, but do not reduce serum urate concentration or prevent progressive joint damage • NSAID +/- Colchicine • NSAID +/- intra-articular corticosteroids
- 7. NSAID • Drug choice & dosage: Indomethacin 50mg TDS, Diclofenac 50mg TID, Ibuprofen 800mg TDS. Most effective when initiated within 48 hours of symptom onset • If flare occurs during ULT flare prophylaxis with an NSAID, increase to full dose of NSAID until flare solves • Stop treatment 2 to 3 days after symptoms resolved • Adverse effects: GI discomfort, hypertension, hypersensitivity reaction • Contraindication: Renal impairment, active GI disorder, asthma, CV disease and known NSAID allergy • DDI: Anticoagulants, Antiplatelets, Triple whammy (ACE inhibitors + NSAID + thiazide diuretics)
- 8. Colchicine • Indication • To reduce pain & inflammation in acute gout • As flare prophylaxis when starting or increasing ULT (different regimen) • Dosage: Colchicine 1.2mg ASAP, then 0.6mg 1 hour later on day 1. Continue with 0.6mg OD or BD as tolerated for the duration of gout. • Resume prophylactic colchicine with a gap of at least 12 hours • Adverse effects: Diarrhea, vomiting, abdominal pain • DDI: P-gp inhibitors (macrolide antibiotics), CYP3A4 inhibitors (antifungals) • Contraindication: severe renal or hepatic impairment, concurrent medication of strong CYP34A or P-gp inhibitors
- 9. Corticosteroid (Oral/IM/IV) • When NSAID or colchicine are inappropriate (pt taking coagulation) • Oral dosage: Prednisolone 15mg to 30mg daily, typically 3 to 5 days until symptoms resolved • Joint injection: A single dose of intramuscular corticosteroid injection, triamcinolone acetonide 40/30/10mg at up to a maximum of two affected sites • Adverse effect: Diabetes, hypertension, weight gain
- 10. Long-term management of gout with ULT • Allopurinol 50mg for 4 weeks; increase up to 900mg daily • Febuxostat 40mg daily for 4 weeks; increase up to 120mg daily • Probenecid 250mg BD for 1 week; increase up to 2g daily • Rationale: lower serum urate below target concentration to dissolve crystals, so stopping acute flares, joint destruction and resolve tophi • Optimal time to start ULT is delayed until flare has resolved; Appropriate to start ULT concurrently with gout flare treatment provided flare treatment is adequate and risk of flare is well informed • Need to be taken for lifelong • Starting or increasing ULT is associated with high risk of gout flare therefore given together with NSAID or colchicine
- 11. • Adjunct treatment for gout • Relieve painful symptoms of gout by breaking up the uric acid crystals that accumulate in the joints • Ingredient: Sodium bicarbonate 1760mg, sodium citrate 630mg, citric acid 720mg, tartaric acid 890mg • Dosage: Take 1-2 sachets, 4 times daily [Total of 4-8 sachets] • Drink plenty of water Adjunct treatment: Urinary alkaliniser
- 12. Dietary supplement: Tart cherry extract & bromelain • Lower serum uric acid by flushing out uric acid to prevent build-up • Inhibit COX-1 & COX-2 to provide inflammatory effect • Therefore quickly stop gout attacks in progress while preventing future attacks from occurring • Dosage for acute gout attack: 1 sachet 3 times a day • Dosage for maintenance: 1 sachet 2 times a day • Can safely be taken with gout medication • Other benefit: exercise recovery, cardiovascular health, enhance sleep quality
- 13. Counselling point • Avoid purine-rich food (Meat, seafoods, and sweet drinks) • Limit alcohol consumption • Advise resting & apply ice pack on affected joint until onset of drug’s effect • Review concurrent medication that decreases uric acid excretion (Thiazide can cause hyperuricemia and should be substituted with other diuretics) • Stay hydrated • Check uric acid level twice a year • Emphasize the importance of being adherence to ULT (even flare up occurs)
Editor's Notes
- The topic im going to talking about is the management of gout, specifically focus on acute gout management
- Gout is a type of arthritis – often call as crystal arthritis because of the deposition of urate crystal in joints, soft titssues and kidneys Gout happen when the serum uric acid is persistently elevated more than 0.42mmol/L//7mg/dL (milligram per deciliter) The incidence of gout is usually increased with age from 40yo but gout is very treatable if patient has good adherence to lifelong urate lowering therapy (ULT) If the gout is not treated promptly, the collection of solid urate can cause destructive changes in surrounding tissue – we call it tophaceous gout Therefore it’s important to emphasize importance of being adhere to ULT to patients
- Talking about the symptoms: the first attack of gout is usually monoarticular (usually the big toe) But it can also affect other part of body such as ankle, heel, knee and wrist It can be very painful, red, swollen & the pain typically throughout the night However, symptoms usually subside within 1 week if not treated but patient usually seek medical advice, so our aim of management is to provide rapid symptom relief
- Taking about the risk factors of gout Gout is more common in male Deficiency in the HPRT enzyme can also lead to overproduction of uric acid – it can be the genetical risk factor Other risk factors include: Purine-rich diet, high alcohol consumption, fructose-sweetened drinks which can breakdown into uric acid in the blood Concurrent medication that inhibit uric acid excretion such as thiazide Reason behind: uric acid is eliminated by kidney (2/3) – drugs that inhibit renal excretion of uric acid can increase serum uric acid concentration. Recent initiation of ULT can also precipitate gout flare but beneficial in long-term
- How does gout happens? Patients with risk factors mentioned just now will experience increased uric acid production/ decreased excretion of uric acid Therefore the uric acid accumulate in the body leading to formation of urate crystal. When the urate crystal is accumulated then it will deposit in the joints The formation of urate crystal will interact with inflammatory system releasing inflammatory mediators. Therefore inflammatory reaction (pain, swelling) seen in the joints If they are treated promptly with treatment it can help to prevent complication such as renal damage and formation of tophi
- Talking about the management of flare up in gout Our main focus is to provide symptomatic relief The treatment can be either NSAID alone, NSAID + colchicine/ addition of corticosteroid
- NSAID is routinely given for patient without contraindication Common drug of choice include: diclofenac 50mg TID. It’s most effective when given within 48h of symptom onset NSAID shouldn’t be taking long term. Therefore must inform patient to stop taking it after symptoms has resolved There are some adverse effect of NSAID need to take note of: they can cause GI discomfort, hypertension, hypersensitivity reaction (if patient has previous allergic reaction reported) NSAID is contraindicated in those with severe renal impair, active GI disorder, asthma, pt with cardiovascular disease and known severe NSAID allergy It can interact with other medication as well, such as anticoagulants, antiplatelet, and will cause AKI due to triple whammy effect if pt taking ACEi & diuretics together with NSAID Therefore, proper medication history taking should be done
- Colchicine is another medication can be use to reduce pain & inflammation during acute gout It can also be given as flare prophylaxis when starting or increasing ULT The usual dosage for acute flare is: 1.2mg ASAP, then 0.6mg 1 hour later on day 1. Continue with 0.6mg OD or BD as tolerated for the duration of gout For those patient has been taking colchicine as prophylactic therapy, resume it for a least a gap of 12 hours to avoid toxicity The adverse effect of colchicine include: diarrhea, vomiting, abdominal pain. Therefore patient should stop taking it whenever they experience these One thing to take note about colchicine is that is has many DDI. Take note if patient taking p-gp inhibitors (macrolide antibiotics), CYP3A4 inhibitors (antifungals) because concurrent use of them can cause toxicity. Prophylaxis dose: 0.6mg OD or BD according response & GI symptoms. Usually use during the first 6 months of ULT. Colchicine may be used instead of NSAID in heart failure as it doesn’t cause fluid retention
- Corticosteroid is usually reserve for candidate that cannot tolerate NSAID or colchicine or they are unable to tolerate orally Will not talk much on this because corticosteroid require prescription from doctor
- The long-term management of gout is slightly different from flare up management Drugs that usually given as ULT are allopurinol, febuxostat, probenecid Their principle of action is to lower serum urate below target concentration to dissolve the crystal. Therefore stopping acute flares, joint destruction & resolve tophi – it should be taken for lifelong and adherence is the crucial to manage the symptoms For the very first episode of gout, the optimal time to start ULT is usually delayed until flare has resolved. But practically, it’s not wrong to start ULT concurrently while having gout flare treatment provided that risk of having 2nd flare is well informed Starting during flare is thought to worsen the existing flare
- Next, urinary alkaliniser can also be recommended as adjunct treatment for gout The ingredient in urinary alkaliniser increase excretion of acid element in urine and raises the pH value of urine. Raising urinary pH makes urine become more alkaline & will promote dissolution of uric acid crystals. Therefore relieve painful symptoms of gout. Dosage recommended for gout patient is usually 1-2 sachets 4 times daily. Advise patient to drink plenty of water and stay hydrate so that it can flush out the uric acid from body.
- Tart cherry is good for gout because contains a high amount of antioxidant & anthocyanins 1 and 2 to block cox enzyme – therefore can that help to relieve pain & inflammation It can help to stop gout attack in progress and prevent future attacks Dosage for gout attack is 1 sachet 3 times daily; while if it’s use as maintenance then 1 sachet 2 times daily Improve CV health: reduce c-reactive protein & lower total cholesterol Bromelain best known for its enzymes (proteases) to help break down foods for healthy digestion. These enzymes also contribute to joint health. Work to foster absorption of certain nutrients include glucosamine, sulfur, both present in joints & crucial for ongoing joint comfort.
- These are some important counselling point we should take note when counselling patient with acute gout If we identified that diet is the trigger factor of the gout: advise pt to cut down intake of purine-rich food such as meat, seaffods, sweet drinks Sudden high alcohol consumption can sometimes be the risk factor also We can advise patient to rest & apply ice pack on affected joint while waiting the drug to be effect Most importantly, we should make use of the medication history taking session to find out if pt taking other medication that cause uric acid build up in the body. Consider to substitute to other class of drug or contact GP if required Advise patient to stay hydrated & routinely checkup on uric acid level Last but not least, we should highlight the importance of being adherence to ULT & reassure the flare up happen when initiating ULT is normal as it indicated that the treatment is working.