Management

1. Management

2. Problems • Chronic tophaceous gout in flare • Ulcers on sole of left foot • Leukocytosis with neutrophilia • Anemia and possible GI bleeding • Hypertension

3. Therapeutic goals • Treat acute gouty arthritis • Wound management for ulcers on sole of left foot • Treat infection • Treat anemia and GI bleeding • Manage hypertension

4. Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

5. In the absence of contraindications 4 tablets in divided doses per day initially at 30 mg and rapidly tapered over 6 days can be given as alternative Allopurinol started at 100 mg/day 2 weeks after the pain and swelling has subsided. Dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve SUA <6 mg/dL. The maximum dose of allopurinol is 300 mg/day. SUA and serum creatinine should be periodically monitored. Li-Yu J, et al. (2008) Philippine Clinical Practice Guidelines for Uncomplicated Gout. Philippine Rheumatology Association. Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

6. Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

7. Absence of response after a week should prompt re-evaluation of the diagnosis and referral to a rheumatologist Li-Yu J, et al. (2008) Philippine Clinical Practice Guidelines for Uncomplicated Gout. Philippine Rheumatology Association. Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

8. In the absence of contraindications, i.e.. renal impairment or gastrointestinal ulcers, the use of colchicines, traditional non-steroidal anti-inflammatory drugs (NSAIDs), OR selective cyclo-oxygenase 2 (COX-2) inhibitors is recommended for the treatment of acute gouty arthritis. • The expert panel recommends that colchicines should not exceed 4 tablets in divided doses per day. • Prednisone, initially at 30 mg and rapidly tapered over 6 days can be given as alternative if colchicines, traditional NSAIDs or COX-2 inhibitors are contraindicated or not tolerated by the patient • Absence of response after a week should prompt re-evaluation of the diagnosis and referral to a rheumatologist • Ice compress is recommended in combination with pharmacologic agents for relief of joint pain and swelling of acute gouty arthritis Li-Yu J, et al. (2008) Philippine Clinical Practice Guidelines for Uncomplicated Gout. Philippine Rheumatology Association.

9. Serum uric acid (SUA) level should be reduced to and maintained at <6 mg/dL (0.36 mmol/L) • Continuous long term therapy with allopurinol is advised to achieve a target SUA level of <6 mg/dL • Allopurinol should be started at 100 mg/day 2 weeks after the pain and swelling of gouty arthritis has subsided. The dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve SUA <6 mg/dL. The maximum dose of allopurinol is 300 mg/day. SUA and serum creatinine should be periodically monitored. • A referral to an internist or rheumatologist is recommended if SUA persistently remains > 6 mg/dL despite maximum dose. • Colchicine should be used at 0.5 mg/tab OD BID to prevent gout flares when initiating urate-lowering therapy with allopurinol. This should be maintained for 3-6 months from the last occurrence of gout flare and after the optimal SUA target is achieved. In the event that adverse events like diarrhea occur, a lower dose of colchicines should be used. NSAIDs should not be used for prevention of gout flares. • Dietary modification (to promote weight loss) and avoidance of alcohol should be prescribed. • Low impact exercises (walking, biking, swimming, ballroom dancing) may also be advised. Li-Yu J, et al. (2008) Philippine Clinical Practice Guidelines for Uncomplicated Gout. Philippine Rheumatology Association.

10. Management of acute gout (1) Affected joints should be rested and analgesic, anti-inflammatory drug therapy commenced immediately, and continued for 1–2 weeks. (2) Fast-acting oral NSAIDs at maximum doses are the drugs of choice when there are no contraindication. (3) In patients with increased risk of peptic ulcers, bleeds or perforations, co-prescription of gastro-protective agents should follow standard guidelines for the use of NSAIDs and Coxibs. (4) Colchicine can be an effective alternative but is slower to work than NSAIDs. In order to diminish the risks of adverse effects (especially diarrhea) it should be used in doses of 500g bd–qds. Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

11. (5) Allopurinol should not be commenced during an acute attack but in patients already established on allopurinol, it should be continued and the acute attack should be treated conventionally. (6) Opiate analgesics can be used as adjuncts. (7) Intra-articular corticosteroids are highly effective in acute gouty monoarthritis and i.a., oral, i.m or i.v corticosteroids can be effective in patients unable to tolerate NSAIDs, and in patients refractory to other treatments. (8) If diuretic drugs are being used to treat hypertension, an alternative antihypertensive agent should be considered, but in patients with heart failure, diuretic therapy should not be discontinued . Jordan, KM, et al. (2007). Guideline for Management of Gout. British Society for Rheumatology

12. Wound Management • Debridement may he accomplished by sharp, mechanical, enzymatic, and/or autolytic measures. • Wounds should be cleaned initially and each dressing changed by a nontraumatic technique. • Use normal saline • Selection of a dressing should ensure that the ulcer tissue remains moist and the surrounding skin dry. James, WD, et al. (2006). Andrews’ Diseases of the skin: Clinical Dermatology, 10th ed.

13. Leukocytosis with neutrophilia • Broad spectrum antibiotics which one??

14. Anemia and GI bleeding • Proton pump inhibitor (Omeprazole) • Blood transfusion

15. Hypertension …which one?? • Diuretics • Anti-adrenergics • Adrenoceptor Blockers • Alpha Adrenoceptor Blockers • Beta Adrenoceptor Blockers • Adrennergic Neuron Blockers • Centrally Acting Anti-hypertensives • Direct Vasodilators • Calcium Channel Blockers • Angiotensin Converting Enzyme (ACE) Inhibitors • Angiotensin 2 Receptor Blockers (ARB)

16. Given in ward • Omeprazole 40 mg tab OD • Amlodipine 10 mg tab OD • Clindamycin 300 mg cap q 6 • Ciprofloxacin 250 mg tab BID • Given Colchicine as follows to treat acute gout: 2 tabs now then 1 tablet after 6 hours • Cold compress x 10-15 mins TID on inflamed joints

17. Thank you!!!

18. Febuxostat • nonpurine selective inhibitor of xanthine oxidase. • acts by binding into a channel in the molybdenum center of the enzyme, leading to a very stable and long-lived enzyme-inhibitor interaction with both the oxidized and reduced forms of the enzyme and, as a consequence, a strong inhibition of substrate binding Gaffo, AL and Saag KG. (2009). Febuxostat: the evidence for its use in the treatment of hyperuricemia and gout. Core Evid 4:25-36

20. ANTIGOUT • For acute gout • COLCHICINE Oral: 500 mcg tablet • NSAIDs • For chronic gout • ALLOPURINOL Oral: 100 mg and 300 mg tablet PNDF Vol. I, 7th ed. (2007)

21. 2.4 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) • 2.4.1 Non-selective COX inhibitors • IBUPROFEN • NAPROXEN • diclofenac • indometacin • ketoprofen • mefenamic acid • 2.4.2 Selective COX 2 inhibitor • CELECOXIB PNDF Vol. I, 7th ed. (2007)