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.

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.