Contentious Issues In Gout Management

Content

• Is The Use Of Benzbromarone Indicated For The Treatment Of Gout?
• How A Gout Flare
• Types Of Pain
• What Increases Your Chances For Gout?
• Colchicine

Probenecid acts by inhibiting reabsorption of uric acid in the proximal tubules of the kidney. Starting dose is at 500 mg to 1000 mg daily and increased to 1500 mg to 2000 mg as needed. Probenecid may precipitate renal stone formation and good oral hydration should be encouraged. Probenecid is contraindicated in patients with renal stones and in patients with urate nephropathy. Probenecid given inappropriately to patients with hyperuricemia due to overproduction of uric acid can cause renal stones and urate nephropathy. It is important to note that whenever starting a uric acid lowering treatment, there is a risk of precipitating a gout flare.

When treating a gout attack, the goal is to relieve pain and inflammation. When treating chronic gout, the goal is to prevent future gout attacks and long-term joint damage. Joint aspiration subjected to polarized light microscopy is especially critical when differentiating gout from CPPD . latest clinical trials has prompted releasing updated guidelines that will improve patient care for the affected population. Standardization of a treat-to-target strategy for urate lowering therapy is the key focus because of its benefit for all patients with gout. In this report, we elucidate a protocol for network meta-analysis of using drug therapy to treat acute gout, which is a prevalent public health problem.

Is The Use Of Benzbromarone Indicated For The Treatment Of Gout?

Because there is no high-quality evidence, the ACP guideline committee could not endorse a treat-to-target strategy. The committee was aware that this finding would not be well received by many in the rheumatology community and was braced for the resulting controversy, Dr. McLean added. "The ACP is not drawing a line in the sand. We are saying what the data indicate, and because we are following the strict directives on what a guideline should be based upon, we can't say more than this," he said. "Gout is a devastating, crippling, and painful disease," he said, adding that he is "not in favor of setting patient care back in gout by about 50 years" by not treating to target. Contact Carolina Arthritisfor guidance and to learn more about this strategy for your gout attacks.

How do you treat an acute gout flare up?

Oral corticosteroids, intravenous corticosteroids, NSAIDs, and colchicine are equally effective in treating acute flares of gout. 20 NSAIDs are the first-line treatment. Indomethacin (Indocin) has historically been the preferred choice; however, there is no evidence it is more effective than any other NSAID.

If a patient is allergic to allopurinol, there are often limited options. If the rash was relatively mild, one option is an oral desensitization regimen for that agent. Along with diet, physical activity can help with weight loss, and gout has been associated with being overweight. Treatments used for prevention, such as allopurinol can actually make things worse if given during an attack, and so need to be held back until the attack has resolved for several weeks. Collections of uric acid need to be searched for, and they can be in numerous locations (see Figures 7-10). X-ray shows characteristic changes of gout, including cysts in bone and erosions.

How A Gout Flare

Your PCP may send you to a rheumatologist, a doctor who specializes in gout and other kinds of arthritis. Some people have gout attacks frequently, while others go years between episodes. If gout isn’t treated, attacks may become more frequent and last longer. Gout attacks can happen over and over again in the same joint or affect different joints.

The choice of which treatment is the right one for a particular patient should be made on the basis of the patient’s co-morbid medical conditions, other medications, and side effect profile. Microscopy of joint fluid is used less often, primarily in equivocal cases. In these situations, the diagnosis is established by aspiration of a joint or tophus and identification of needle-shaped monosodium urate crystals, preferably intracellular, with bright, negative birefringence on compensated polarized light microscopy. Ultrasonography, magnetic resonance imaging, and computed tomography are typically not necessary for diagnosis. To prevent recurrent gout, patients should reduce their consumption of high-fructose corn syrup–sweetened soft drinks, fruit juices, and fructose-rich vegetables and fruits (e.g., applesauce, agave).

In this process, oversaturation of synovial fluid with MSU crystals occurs, leading to nocturnal onset of attacks. It is possible that factors causing increased articular concentration of crystals, despite normal serum uric acid, may cause protracted arthritis. Another hypothesis to explain refractory attacks could be the low serum uric acid levels promoting tophi dissolution due to the concentration gradient.

Pegloticase is an option for the 3% of people who are intolerant to other medications. Pegloticase is given as an intravenous infusion every two weeks, and reduces uric acid levels. Pegloticase is useful decreasing tophi but has a high rate of side effects and many people develop resistance to it.

Inhibition of both CYP3A4 and P-gp by dual inhibitors such as clarithromycin has been reported to produce life-threatening or fatal colchicine toxicity due to significant increases in systemic colchicine levels. Therefore, concomitant use of colchicine capsules and inhibitors of CYP3A4 or Pglycoprotein should be avoided . If avoidance is not possible, reduced daily dose should be considered and the patient should be monitored closely for colchicine toxicity.

Gout affects 8 million Americans in the United States, or 4% of the population, rising to 10% within the senior population. With this chronic condition, uric acid crystal build-ups cause severe and debilitating pain. The incidence of gout has been increasing sharply in most western countries in the last decades, and often goes undertreated, leaving patients suffering unnecessarily. At The Center for Primary Healthcare, our goal for gout patients is to eliminate your gout flare ups. William Crevier, MD, and Suzanne Deese, MSN, APRN, CNP, help men and women living in Orland Park, Illinois, manage their gout symptoms and prevent breakouts. If you think you’re experiencing gout, schedule an appointment with the office today on the phone or online.

These early studies of cherry juice are interesting, and might be relevant for a patient who was "almost there" in their uric acid goal, but a gout sufferer should be very careful about trusting to cherry juice to manage their uric acid. Based on the data, the result is likely not going to be sufficient. It is not approved for use in people with significant decrease in kidney function, and some patients have had worsened kidney function while taking lesinurad. Lesinurad is taken once a day, so more convenient than probenecid. In theory this medication, like probenecid, can increase the risk of uric acid-induced kidney stones, but this was minimal risk in published studies and the combination with either allopurinol or probenecid likely dramatically reduces this risk. Lesinurad is now available in combination with allopurinol, allowing a person taking both medications to take a single pill a day.

Using parenteral corticosteroids confers no advantage unless the patient cannot take oral medications. In February 2008, the US Food and Drug Administration ruled that intravenous colchicine can no longer be produced or shipped in the United States, because of its toxicities. Consequently, IV colchicine is no longer advocated for the treatment of acute gout in the United States. Limit NSAID use in elderly patients, because of the potential for adverse central nervous system effects. Use NSAIDs cautiously in patients with diabetes and those who are receiving concomitant angiotensin-converting enzyme inhibitors.

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