Contentious Issues In Gout Management

Content

• Managing An Acute Flare
• All About Gout For Primary Care: Treating Acute Gout
• New Gout Treatment Guideline Emphasizes Genetic Risks

Additionally, intra-articular glucocorticoids have been anecdotally associated with rebound attacks . However, the Fernández study had no such attacks occur among participants. 12 Finally, septic arthritis must be ruled out as in any case of acute onset monoarticular arthritis. Uricase is an enzyme that converts poorly soluable urate to the more soluable allantoin . Uricase is present in most mammals, and these mammals with uricase do not develop gout.

Managing An Acute Flare

Gastrointestinal disorders are the most common adverse reactions with colchicine. They are often the first signs of toxicity and may indicate that the colchicine dose needs to be reduced or therapy stopped. Nonpharmacological methods advocated for managing hyperuricemia in patients with gout include weight loss, exercise, alcohol restriction, sufficient hydration, and dietary changes. Urate-lowering medications are the primary pharmacological intervention for managing hyperuricemia.

You may want to download and complete the Gout Flare Questionnaire before your appointment. Gout is a readily treatable and rewarding disease to manage because of the current and expanding therapies available. In adopting a comprehensive approach to gout care, it is imperative that healthcare providers consider and search for associated comorbidities. Furthermore, therapeutic strategies should be guided by the global health of the patient, keeping in mind the significant drug interactions and side-effect profiles that complicate disease management. Although nondrug therapy certainly plays an important role in gout management, pharmacologic therapy remains the mainstay. Although a complete review of purine metabolism, uric acid handling, and the pathogenic mechanism of clinical gout is beyond the scope of this article, a brief overview of each is warranted to better comprehend current therapeutic strategies for gout.

All About Gout For Primary Care: Treating Acute Gout

All patients were followed for 36 months from their first documented high serum uric acid level. A gout attack usually occurs when something triggers a spike in uric acid levels or a shift in the crystals in the joint. Gout left untreated can result in symptoms lasting 10 to 14 days on average. Complications of untreated gout include chronic pain and permanent joint damage.

What kills uric acid in the body?

Natural Ways to Reduce Uric Acid in the BodyLimit purine-rich foods.
Avoid sugar.
Avoid alcohol.
Lose weight.
Balance insulin.
Add fiber.
Reduce stress.
Check medications and supplements.

Patients also initiated ULT at baseline with allopurinol, febuxostat or benzbromarone, at the discretion of the treating rheumatologist. A five-day treatment of anakinra was non-inferior to registered treatment as usual in treating acute gout flares. Now that the FDA has put this warning on febuxostat, even in people with kidney abnormality we would be likely to start allopurinol first. For people already on febuxostat who never took allopurinol, it is an individual case decision about whether to switch to allopurinol.

Gout And Diet

The optimal therapy is towards controlling pain and inflammation Drug therapy for gout has become an important part of the therapeutic approach to the disease, which includes lifestyle modifications. Current standards for first-line treatment for acute attacks include nonsteroidal anti-inflammatory drugs , colchicine and corticosteroids. Urate-lowering treatment is usually recommended after the acute attack has resolved. Physiologically, during day time, the synovial fluid is able to maintain a constant concentration of intra-articular monosodium urate crystals. At night, there is an articular dehydration attributed to joint rest, causing the passage of interstitial fluid to the circulatory system.

The concomitant use of colchicine capsules and inhibitors of P-glycoprotein (e.g. clarithromycin, ketoconazole, cyclosporine, etc.) should be avoided due to the potential for serious and life-threatening toxicity . The concomitant use of colchicine capsules and CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole, grapefruit juice, erythromycin, verapamil, etc.) should be avoided due to the potential for serious and life-threatening toxicity . Colchicine is a substrate of the efflux transporter P-glycoprotein (P-gp), and the CYP3A4 metabolizing enzyme.

The inflammatory process in the mechanism of decreased serum uric acid concentrations during acute gouty arthritis. Acute gout care, especially in the context of comorbidities, has been identified as a critical treatment concern by an international panel of rheumatologists as part of the 3e Initiative. 16 However, regular clinical trial exclusion criteria have limited data necessary to guide treatment when comorbidities are present.

Repeated attacks can be prevented by medications that reduce serum uric acid levels. Tentative evidence supports the application of ice for 20 to 30 minutes several times a day to decrease pain. Options for acute treatment include nonsteroidal anti-inflammatory drugs , colchicine, and Glucocorticoids. While glucocorticoids and NSAIDs work equally well, glucocorticoids may be safer.

Arranging for adequate follow-up after gouty flare should be considered part of inpatient treatment, Dr. Bongartz said. “Either patients are already on these agents in the hospital or there's always a risk that somebody puts them on them and isn't aware of these potential interactions. So colchicine is also something I'm trying to avoid,” Dr. Bongartz said. Some physicians, including Dr. Bongartz, try to avoid using NSAIDs, however, because of potential kidney side effects. This site is for educational purposes only; no information is intended or implied to be a substitute for professional medical advice. The information is produced and reviewed by over 200 medical professionals with the goal of providing trusted, uniquely informative information for people with painful health conditions.

Learn about symptoms, causes, treatments and medication for this painful condition. An area of research with the potential to change the field of gout is understanding the underlying genetics. However, the knowledge gap regarding the effect of genetic testing on clinical outcomes contributes to this approach not being part of the standard of care. Two case reports had outcome results stratified by renal function, but further conclusion could not be drawn due to the low level of evidence for these studies . These two literature searches were subsequently merged prior to the screening phase. This search strategy was applied to all gout flare prophylaxis/therapy, except for glucocorticoids.

None of these episodes of drop in blood pressure led to death or long-term problems for the patients, however, and the blood pressure returned to baseline in these cases. The drop in blood pressure is still a concern, and this medication must be used in a setting where treatment of the drop in blood pressure can be managed. Pegloticase may be especially useful in patients with very large collections of uric acid , especially if these are draining to the skin.

Medical Management Current Best Evidence:

For those interested in achieving the maximal lowering of uric acid by dietary means, two “Gout Haters Cookbooks” are listed in the “Books about Gout” section below. Although alcohol can bring on gout attacks, genetics are much more important than alcohol in defining who gets gout, and many who never drink alcohol suffer from gout. This situation has been mimicked in more recent times when imbibers of “moonshine whiskey,” often made in radiators containing lead, developed a lead poisoning-associated gout (“Saturnine gout”).

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