What is the goal serum uric acid level for treatment of gout?
Less than 6 mg/dL
What meds can increase risk of hyperuricemia?
Niacin
Thiazide and loop diuretics
Immunosuppressants
How is gout categorized by severity?
0-10 pain scale
- Mild is 4 or less
- Moderate is 5-6
- Severe is 7 or higher
How is gout categorized by onset?
Early - less than 12 hrs onset
Well established - 12 to 36 hrs after attack
Late - over 36 hrs since attack
How is the extent of gout categorized by joints?
- One or a few small joints
- 1 or 2 large joints (ankle, knee, wrist, elbow, hip shoulder)
- Polyarticular w/more than 1 region (4 or more joints)
Acute gout attack treatment
- NSAIDs
- Colchicine
- Corticosteroids
When should treatment be started with an acute gout attack?
Within 24 hrs if possible
NSAID use in gout
- No specific preferred (MC are indomethacin and naproxen)
- Full dose until attack is resolved (3-5 days)
- COX2 inhibitor can be used (high doses needed)
- ADEs are GI, HTN, dizzy, CV events, tinnitus
MOA colchicine in gout
Decreases microtubule assembly and inhibits activation of inflammatory response
1st line treatment of mild to moderate gout?
Monotherapy of either:
- NSAID (or COX2 inhibitor)
- Systemic steroids
- Colchicine
ADEs of colchicine
- Abdominal pain, cramping, vomiting, diarrhea
- Monitor in renal and hepatic impairment
- Narrow therapeutic range before toxicity
How should colchicine be taken?
With plenty of water
What can increase levels of colchicine?
Grapefruit juice
Drug interactions with colchicine
- Clarithromycin
- Statins
- Digoxin
How do corticosteroids work in gout?
Suppresses migration of PMN leukocytes and decreases immune repsonse
ADEs of corticosteroids
- Hyperglycemia
- Dyspepsia, nausea
- Mood changes
- HTN
How should corticosteroids be taken in gout?
- With food
- Can be given intra-articular
- Use for 5-10 days then discontinue (oral)
Nonpharm prevention of gout
- Diet (decrease purines, HFCS, sugar and salt)
- Reduce weight
- Exercise
- Reduce ETOH
- Increase fluids, rest and ice
What are the urate-lowering treatment criteria?
- Pts w/tophi
- 2 or more attacks per year
- Stage 2 to 5 CKD
- History of uric acid kidney stones
Xanthine oxidase inhibitors
Allopurinol and febuxostat
What is the 1st line treatment for gout prevention?
Xanthine oxidase inhibitors (allopurinol, febuxostat)
Should xanthine oxidase inhibitors be stopped during acute gout attacks?
NO - add colchicine or NSAID
Allopurinol ADEs
- Hypersensitivity in pts taking ACEI and diuretics
- Rash MC w/concurrent amoxicillin/ampicillin
Who is at high risk for allopurinol hypersensitivity?
HLA-B 5801 (Koreans, Han Chinese, Thai)
