Gout Treatment Guidelines Revamped After New Clinical Guidance

Content

• Find A Doctor Near You? Yes, But Medical Booking Sites Have Downsides, Too
• Is Colchicine Safe?
• Pathophysiology And Risk Factors
• Patient Instructions
• Ascertainment Of Gout
• Managing An Acute Flare

Tophi in and around joints may eventually cause deformities and secondary osteoarthritis. It is known that allopurinol generally is used in low doses, below 300 mg, achieving low uric acid levels (below 5 mg/dL) in only 26% of patients. However, the increase to 600 mg may improve the success rates to 78% . No specific agent is significantly more or less effective than any other.

His gout flares lasted 5 to 14 days and occurred on average one time per month. Initial laboratory tests revealed serum uric acid 5.5 mg/dL, 24-hour uric acid urinary excretion level 194 mg/24 h, and uric acid clearance 2.4 mL/min. At this point, benzbromarone 100 mg daily was introduced, in order to increase urinary uric acid excretion. Despite good adherence, on September 2010, the patient developed a new episode of acute polyarticular gouty arthritis, affecting wrists, knees, ankles, right elbow, and first metatarsophalangeal joints. Serum uric acid was 3.7 mg/dL, 24-hour urine uric acid level 317 mg/24 h, uric acid clearance 5.9 mL/min, and creatinine 1.9 mg/dL.

Find A Doctor Near You? Yes, But Medical Booking Sites Have Downsides, Too

Symptoms of dehydration include headache, lightheadedness, constipation, and bad breath. Treatment for dehydration is to replace lost fluids and electrolytes. There is ongoing research in using a specialized CT scan known as a dual energy CT scan to diagnose gout. There is also a great deal of research investigating the various uric acid transporter genes that are responsible for uric acid metabolism. Drinking beverages sweetened with sugar or high fructose corn syrup increases the risk of gout. However, drinking wine does not appear to increase the risk of gout.

When used as one or two tablets a day (0.6mg each), most people tolerate this medication well, and this dose can help prevent gout attacks. Some physicians would start colchicine after one very severe or two moderately severe attacks of gout, and beyond that, use allopurinol. If a patient has two attacks of gout within the same 12 months, it is generally recommended that they be treated with a medication to lower the uric acid, which colchicine does not accomplish. See below for discussion of the uric acid-lowering agents, allopurinol and probenecid. There is a rare effect on the nerves and muscles with long-term use of colchicine, and a blood test from the muscle is monitored at approximately six-month intervals in patients taking colchicine on a regular basis. Colchicine also has a major role when patients are beginning therapy with allopurinol to prevent the increase in gout attacks that can happen when allopurinol is begun.

Is Colchicine Safe?

The dietary modifications detailed above can be very effective in certain patients. Drinking plenty of water to remain well-hydrated can be beneficial in preventing gout attacks. The most reliable method to diagnose gout is by demonstrating uric acid crystals in joint fluid that has been removed from an inflamed joint . Specially trained physicians, such as a rheumatologist or orthopedist, can carefully remove fluid from the joint. The fluid is then examined under a microscope to determine if uric acid crystals are present. This is important because other medical conditions and diseases, such as pseudogout and infection, can have symptoms similar to gout.

Compliance is often a problem when treating chronic asymptomatic conditions. Perhaps more importantly, patients may have to initially take up to three different medications on different schedules for gout, and that’s confusing. Presumably, patients who understood why they were taking medications would likely be more compliant. The senior author has developed an analogy that helps some patients with compliance . Whatever the technique, establishing an alliance with the patient to achieve compliance is critical.

Refractory Gout Management

One case report of anakinra use described a decline in renal function . In terms of anakinra’s safety profile, 4 studies reported non-fatal infection-related adverse events . The case report on canakinumab use described good efficacy in treating gout flare without any compromise in renal function or in safety signal .

Why is gout so painful?

If people do not take long-term treatment for gout, uric acid can sometimes form kidney stones. The drugs used to relieve symptoms of a gout attack do not get rid of uric acid crystals in the joints or reduce the level of uric acid in the blood, but ongoing treatments, like allopurinol, can do this.

The promise of a small molecule, presumably a less expensive and more convenient approach to inhibition of IL-1B pathway, would be an attractive alternative to biologics. An even more novel approach could evolve from recent evidence that activated CD4+ T cells expressing CD40 ligand regulate the inflammasome [Guard et al. 2009]. In vitro, a CD40 ligand construct, the adiponectin fusion protein (ADIPOQ–CD40L), engages CD40 on activated macrophages and shuts off the NLRP3 inflammasome and caspase-1. This may be a mechanism by which the adaptive immune system dampens the intense innate inflammatory response to urate crystals and other ‘danger’ signals. The second stage of gout is heralded by the first acute attack of gouty arthritis.

Pathophysiology And Risk Factors

MRI and CT are even more sensitive than ultrasound at detecting gout [Thiele and Schlesinger, 2007; Wright et al. 2007; Dalbeth and McQueen, 2009]. As with Rilonacept above, this agent may have a future role in the acute treatment and relatively short-term prevention of gout, and may have a longer-term role in selected patients with problems with multiple other options. Diet has been discussed in more detail above, and gout is clearly one of the rheumatic diseases where diet is unequivocally important. Devil’s claw , curcumin and many other herbal treatments have been proposed as gout therapy, and further study of these is indicated. Cherry juice, which has long been an alternative remedy and which had anecdotal support, now has been studied.

As the prevalence of gout increases worldwide, urate-lowering therapies and lifestyle changes can help to manage the disease. Sedimentation Rate Sedimentation rate is a common blood test that is used to detect and monitor inflammation in the body. It is performed by measuring the rate at which red blood cells settle in a test tube.

Patient Instructions

The annualized frequency of acute gout while receiving IV bumetanide for a heart failure exacerbation is 7.17%. The triggers for precipitation of uric acid are not well understood. While it may crystallize at normal levels, it is more likely to do so as levels increase. Other triggers believed to be important in acute episodes of arthritis include cool temperatures, rapid changes in uric acid levels, acidosis, articular hydration and extracellular matrix proteins. The increased precipitation at low temperatures partly explains why the joints in the feet are most commonly affected. Rapid changes in uric acid may occur due to factors including trauma, surgery, chemotherapy and diuretics.

Is Onion bad for gout?

Eggs are a good protein source for people with gout, because eggs are naturally low in purines.

There were no studies of the effects of colchicine capsules on fertility. However, published nonclinical studies have demonstrated that colchicine-induced disruption of microtubule formation affects meiosis and mitosis. Published reproductive studies with colchicine reported abnormal sperm morphology and reduced sperm counts in males, and interference with sperm penetration, second meiotic division, and normal cleavage in females. Due to the potential for colchicine to produce aneuploid cells , colchicine presents a theoretical increased risk of malignancy. If a dose of colchicine capsules is missed, advise the patient to take the dose as soon as possible and then return to the normal dosing schedule. However, if a dose is skipped, the patient should not double the next dose.

Ascertainment Of Gout

It is not known if colchicine capsules are safe and effective in children. Colchicine capsules are not a pain medicine and it should not be taken to treat pain related to other conditions unless specifically for those conditions. In a published study in healthy volunteers, 40 to 65% of the total absorbed dose of colchicine was recovered unchanged in urine. Enterohepatic recirculation and biliary excretion are also believed to play a role in colchicine elimination.

Of these 130 patients, 18 patients developed symptoms of an acute gout flare, comprising a total of 24 cases. Of these 24 cases of clinically diagnosed gout, 18 met the 2015 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) gout classification criteria. Of the 18 patients, 12 had a known history of gout, and they contributed to 16 cases of acute gout flare. Allopurinol was the only urate-lowering therapy utilized by the treating physicians during an acute gouty flare, as none of the patients were given febuxostat or probenecid. All of the 18 patients with clinically diagnosed gout responded to conventional gout treatment.

Managing An Acute Flare

The patient should avoid trauma to the affected joint; otherwise, they should be active. Lesinurad is the first selective uric acid reabsorption inhibitor approved by the FDA. It acts by inhibiting the urate transporter, URAT1, which is responsible for the majority of the renal reabsorption of uric acid. It also inhibits organic anion transporter 4 , a uric acid transporter associated with diuretic-induced hyperuricemia. White et al reported that all-cause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol (hazard ratio for death from any cause, 1.22; HR for cardiovascular death, 1.34). In February 2019 the US Food and Drug Administration added a black box warning regarding increased risk of death with febuxostat compared with allopurinol.

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