gout 2012: updates to an old disease
DESCRIPTION
Summary of 2012 ACR Recommendations on the Management of Gout. Does not include the approach to the diagnosis of gout.TRANSCRIPT
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GOUT 2012: Updates to an Old Disease
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Assumptions
• Correct Diagnosis
• Consider Co-morbid conditions
• Evaluate for Drug interactions
“The ACR gout guidelines are designed
to emphasize safety and quality of
therapy and to reflect best practice.”
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 ACR Guidelines for Management of Gout. Part 1. Arth Care
& Res 2012; 64 (10): 1431-46. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 ACR Guidelines for
Management of Gout. Part 2. Arth Care & Res 2012; 64 (10): 1447-61.
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Levels of Evidence
A Meta-analyses
>1 Randomized Clinical Trial
B Single Randomized Clinical Trial
Non-Randomized Studies
C Standards of Care
Case Studies
Expert Consensus
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Nomenclature (Acute)
1 2 3 4 5 6 7 8 9 10
SEVERITY (Pain VAS)
DURATION (from onset of symptoms)
0 12 24 36
1 2 3 4 5 6 7 8 9 10
FREQUENCY (No of flares/ year)
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Nomenclature
JOINT INVOLVEMENT
• Few small joints
• 1 or 2 large joints
• Polyarthritis • 4 or more joints
involving >1 region
• 3 large joints
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Nomenclature (CTG)
MILD MODERATE SEVERE
Affects 1 joint Affects 2-4 joints Simple tophi in >4 joints
Stable disease Stable disease OR
Simple tophi Simple tophi >1 Unstable tophus
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Domains in Gout Care
• Acute Gout
• Prophylaxis
• Urate Lowering Therapy
• Chronic Tophaceous Gout
Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 ACR Guidelines for Management of Gout. Part 1. Arth Care
& Res 2012; 64 (10): 1431-46. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 ACR Guidelines for
Management of Gout. Part 2. Arth Care & Res 2012; 64 (10): 1447-61.
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ACUTE GOUT a.k.a. GOUT FLARE
Self limited attack of joint inflammation
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Treating Acute Gout
• Treat with pharmacologic therapy (C)
• Best started within 24 hours(C)
• Do not interrupt those on established urate-
lowering therapy (C)
• Educate patient on
– Initiating treatment when w/ a flare (B)
– Effective urate lowering being “curative” (B)
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Choosing an Anti-Inflammatory
Pain VAS
<7/10
Start
MONOTHERAPY (A)
Start
COMBINATION
THERAPY (C)
Yes
No
CONSIDER
• Patient preference
• Prior response to meds
• Associated co-morbids
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NSAIDs in Acute Gout
• Full anti-inflammatory dose/ acute pain
– Naproxen (A)
– Indomethacin (A)
– Sulindac (B)
– Other NSAIDs (B or C)
– Etoricoxib (A)
– High dose Celecoxib (B)
• Continue until flare completely resolves (C)
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Colchicine in Acute Gout
• Best if given <36 hours of onset
• Dosing regimen
– 1.2 mg initially then 0.6 mg after 1 hour then 0.6 mg
BID until acute gout resolves (A)
– 1.0 mg initially then 0.5 mg after 1 hour then 0.5 mg
TID until acute gout resolves (C)
• Do not give IV
• Reduce in moderate-severe CKD
• Caution with clarithromycin, erythromycin,
cyclosporin and disulfiram
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Steroids in Acute Gout
• Oral or IA steroids if 1-2 joints involved (B)
• IA steroid dose depends on joint size (B)
• Recommended dosing
– Prednisone 0.5 mkd for 5-10 days (A)
– Prednisone 0.5 mkd for 2-5 days then taper
for 7-10 days (C)
– Triamcinolone 60 mg IM with oral steroids (C)
– No consensus for ACTH (A)
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Combination Therapy in Acute Gout
• Colchicine with NSAIDs
• Colchicine with Steroids
• IA Steroids with Colchicine/ NSAIDs/ Oral
Steroids
• Consider topical ice application (B)
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Treating the Patient on NPO
• IA steroids for 1-2 large joints (B)
• IV or IM Methylprednisolone (or equivalent)
0.5 – 2.0 mkd (B)
• ACTH 25-40 IU SC (A)
• No consensus on IM Ketorolac or IM
Triamcinolone (C)
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Contraindications
CONDITION NSAIDs Colchicine Steroids
Chronic Kidney Disease St 3-5
Peptic Ulcer Disease
Heart Failure
Anti-coagulants/ platelets
Diabetes Mellitus
Infection
Liver Disease
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Continuing Acute Gout Care
INADEQUATE
RESPONSE
<20% in 24H
or <50% after
24H
REVIEW the diagnosis
CONSIDER
• Shift to other drug (C)
• Combine therapy (C)
• Anakinra 100 mg SC for
3 days (B)
• Canakinumab 150 mg
SC single dose (A)
COMPLETE
TREATMENT
Yes
No
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PROPHYLAXIS To be started in all patients in whom
Urate Lowering Therapy is indicated
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Drugs for Prophylaxis
• First Line Drugs
– Colchicine 0.5 – 0.6 mg OD-BID (A)
– Naproxen 250 mg BID + PPI (C)
• Alternate Agents
– Prednisone <10mg/d (C)
• Lack of consensus on off-label anti-IL-1 (A)
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Duration of Prophylaxis
Choose the greater of the following:
• 6 months duration (A)
• 3 months of achieving target BUA in patients
without tophi (B)
• 6 months of achieving target BUA AND
resolution of previously noted tophi on PE (C)
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URATE LOWERING THERAPY
Pharmacologic and Non-Pharmacologic
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Diet and Lifestyle Changes
AVOID LIMIT ENCOURAGE
Organ meats (B)
Drinks with fructose(C)
Alcohol overuse (B)
Alcohol during an acute
attack (C)
Seafood (B)
Sweetened fruit juices (C)
Sugar (C)
Salt (C)
Low fat or non-fat dairy
products (B)
Vegetables (C)
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Evaluating Hyperuricemia (C)
• Educate the patient (B)
– Diet and lifestyle changes
– Disease, treatment and objectives
– Role of hyperuricemia and targets
• Consider eliminating non-essential meds that
increase serum uric acid (C)
• Evaluate for co-morbid conditions and
contributors to hyperuricemia (C)
• Assess gout disease burden
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Checklist
COMORBIDS (C)
• Obesity
• Alcohol intake
• Metabolic Syndrome and
components
• Kidney disease
• Lead intoxication
• Myeloprolif/ lymphoprolif
disorders
• Psoriasis
LABORATORIES
• Urinalysis
• Renal ultrasound
• CBC
• Urine uric acid
determination (C)
– Gout < 25 y/o
– Nephrolithiases
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Indications for ULT
• Evidence of tophus/tophi (A)
• Frequent attacks (>2/year) (A)
• History of nephrolithiases (C)
• Chronic Kidney Disease Stage 2-5 (C)
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Target Blood Uric Acid
<6 mg/dl For most gout scenarios
(if without visible tophi)
(A)
<5 mg/dl For more durable
improvement and patients
with visible tophi (B)
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Urate Lowering Therapy
• First Line Agents (A)
– Allopurinol 100-800 mg/d
– Febuxostat 40-120 mg/d
• Alternative Therapy (B)
– Probenecid (except when Cr Cl <50ml/min and history
of urolithisases)
• Can be started during an attack(!) PROVIDED
effective anti-inflammatory therapy has been
given (C)
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Allopurinol Dosing Guide
• Starting dose <100mg/d (B)
– For CKD 4-5, starting dose is 50mg/d (B)
• Titrate up every 2-5 weeks (C)
• Dose of >300mg/d can be used provided patient
is monitored for AHS and other AE (B)
– Pruritus, Rash, Inc LFT, Eosinophilia
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Allopurinol Dosing Guide
Maximum Recommended
Allopurinol Dose Based on Crea
Clearance
Crea Cl (ml/min) Dose
0 100 mg q 3 days
10 100 mg q 2 days
20 100 mg/day
40 150 mg/day
60 200 mg/day
80 250 mg/day
100 300 mg/day
120 350 mg/day
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Pharmacogenetics for AHS
Patients at high risk for AHS should consider
screening for HLA-B*5801 (A)
– Korean descent with CKD 3 or worse (A)
– Han Chinese
– Thai
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Approach to ULT
• Titrate XOI to max recommended dose (A)
• If up-titration is not tolerated or target BUA is
not achieved, consider shift to other XOI (C)
• If target BUA is not achieved, start combination
therapy by adding a uricosuric (B)
• Last option, if still unable to achieve targets on
oral ULT, is to give PEGLOTICASE (A)
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Consider referring when…
• Unclear etiology of hyperuricemia
• Refractory gout
• Difficulty in achieving target BUA
• Multiple or serious AE from ULT
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