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Gout Topic Discussion
Rachel Dietsche
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The Disease
Historically known as the ‘rich
mans disease’
Prevalence in the US is almost 4%
Tophi-deposited MSU crystals and
inflammation
Unknowns:
Why first MTP?
Why acute attacks result from
trauma or urate lowering
therapy?
Why spontaneous resolution?
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Etiology
Result of high uric acid levels
Impaired excretion of uric acid
Overproduction of uric acid
High intake of purine-rich food
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Etiology
Nonmodifiable Risk Factors
Male
Older in age
Pacific Islander ethnicity
Genetic loci SNPs
Modifiable Risk Factors
Obesity
Diet
Alcohol
Fructose/sucrose beverages
HTN
Diuretics
CKD
Cyclosporine, ASA
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Pathophysiology
o Monosodium urate
(MSU)crystals
o Found in synovial fluid
o First metatarsal
phalangeal joint
o Inflammation
o Neutrophils
o Monocytes
o lymphocytes
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Clinical Presentation
flare
painful
red
swollen
warm
Disabling
Skin desqua-mation
WBC 10,000-100,000
Mostly neutrophils
Urate ≥ 6.8mg/dL
Dual energy computed
tomography (DECT)
Urate vs calcium
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Diagnosis
Scoring System
Laboratory Analysis
Physical Findings
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Treatment Guidelines and Alternatives
1st Line Urate Lowering Therapy
Allopurinol
or
Febuxostat
2nd Line Urate Lowering Therapy or
Add-Ons
Probenacid
or
Fenofibrate
or
Losartan **Colchine for treatment of flares or prophylaxis
during intiation of URL**
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Drug of Choice and Monitoring
Allopurinol Initial 100mg daily
Titrate 100mg Q 2-4 Weeks
Screen for HLA-B*5801 variant
Chinese, Thai, Korean
CrCL 10-20: 200mg/d
3-10: 100mg/d
<3: 100mg/d extended intervals
Side Effects Most Common
Rash
Gout flare
Nausea/vomiting
Possible diarrhea and increased
hepatic enzymes
Rare
Bone marrow suppression
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Alternative Drugs and SE/Monitoring
Anakinra
IL- 1 Antagonist
100mg SQ daily for around 3 days to treat an acute flare
CrCl <30: SQ every other day
Side Effects
Most common
Head ache
Vomiting
Infection
Injection site reaction
May increase cholesterol and hepatic enzymes
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References
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American college of rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res. 2012;64. 1431.
Qaseem A, Harris RP, Forciea MA, et al. Management of acute and recurrent gout: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2017;166(1)58-68.
Becker MA, Gaffo AL. Clinical manifestations and diagnosis of gout. UpToDate. Last updated 10/09/2018. Accessed 12/05/18
Allopurinol: drug information. UpToDate. Accessed 12/06/18
Anakinra: drug information. UpToDate. Accessed 12/07/18.