Treatment of gout
Treatment of gout
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Treatment of acute gout flares
| Presenting symptom: Acute gout |
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- Treat acute attack with NSAIDs.
- Use corticosteroids when NSAIDs are contraindicated.
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- Treat resistant cases with addition of low dose colchicine.
- Treat those at risk of NSAID side effects with colchicine alone.
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Evaluate and manage risk factors
(weight, alcohol, diuretics, dietary purines) |
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NSAIDs: given at regular intervals until the severe pain abates, at which time the dose may be reduced (e.g. starting with naproxen 500 mg bd or diclofenac 75 mg bd). Always watch for renal impairment, heart failure and peptic ulceration. If patients are already taking low dose aspirin for cardiovascular risk reduction it should be continued.
Oral corticosteroids: in view of the toxicity of colchicine, corticosteroids may be preferred to treat acute gout in patients in whom NSAIDs are contraindicated, provided sepsis has been excluded. The initial dose is 15–40 mg prednisone daily, gradually reduced over 10 days. Intra-articular corticosteroids are useful if monoarthritis is present to reduce risks of systemic therapy.
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“Allopurinol should not be started at the time of the attack”
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Colchicine: can be a useful adjunct to NSAIDs in resistant cases, particularly when tophi are present, as monotherapy or to prevent flares when starting allopurinol.
Allopurinol: If a patient has been taking allopurinol regularly at the time of developing an acute attack it should be continued at the same dose.
Risk factors for gout |
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The key risk factors for gout are
- Hyperuricaemia
- Male sex
- Māori and Pacific ethnicity*
- Chronic renal impairment
- Hypertension
- Obesity
- Diuretic use**
- Coronary heart disease
- High intake of meat, seafood and alcohol (particularly beer)
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*Māori patients with normal uric acid levels have been shown to have a reduced excretion of urate. This suggests an underlying renal mechanism.4
**Diuretic therapy is a risk factor for the development of hyperuricaemia and recurrent gout attacks. Diuretic therapy should be minimised and avoided wherever possible.
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Colchicine dosing for acute gout
Due to recent concerns about toxicity, colchicine is no longer considered first line treatment for acute gout. In addition colchicine should be used at a lower dose than has been recommended in the past.
“...The recommended dose for colchicine in the treatment of acute gout is 1.0 mg stat, followed by 0.5 mg six hourly, up to a maximum dose of 2.5 mg per 24 hours...”
New Zealand Rheumatology Association (NZRA), endorsed by Medsafe.5
(full statement available at http://www.rheumatology.org.nz/position_statement.cfm)
After the first 24 hours, the dose should be reduced to 0.5 mg one or two times daily, according to renal function. Prescribed in this way colchicine is safe and effective. The risk of diarrhoea and other toxic effects is minimised. Many patients report that one or two colchicine tablets taken within the first few hours of the onset of pain can avoid a major flare.
Adverse effects with Colchicine
Colchicine has a narrow therapeutic margin and considerable variation in absorption between individuals. Toxic effects include diarrhoea, nausea and vomiting, electrolyte imbalance, alopecia, haematological effects, pancreatitis, and failure of kidneys, liver or respiratory system. High doses can be fatal.
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Adverse effects with Allopurinol
The most common adverse effect is a rash (1−2%), which may be more common in patients with renal impairment.12 Allopurinol hypersensitivity syndrome (AHS) is extremely rare but potentially fatal. It is characterised by fever, rash, eosinophilia, hepatitis and renal failure. Adverse effects can occur at any dose.13
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