SlideShare a Scribd company logo
1 of 54
Download to read offline
Welcome
to
University Hospital Sharjah
Treating gout with
clinical guidelines
Professor Sukhbir Uppal
Consultant in Medicine/Rheumatology
MBBS,MD, FRCP(UK), FACR (USA)
University Hospital Sharjah, UAE
Ann Rheum Dis. 2017 Jan;76(1):29-42
Aims and objectives
• Using the 2016 Eular guidelines as a framework, this
presentation aims to achieve the following
objectives:
– Patient education
– Screening for co-morbidities
– Flare treatment and prophylaxis
– Urate lowering therapy
– Management of asymptomatic hyperuricemia
Introduction
• New drugs and new evidence concerning the
use of established treatments have become
available over the last 10 years for the
management of gout.
Rheum Dis Clin North Am. 2014 May; 40(2):
155–175.
Increasing incidence of gout in
men and women with serum
urate level
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Barriers
• Recent studies report that less than half of the
patients with gout receive ULT , and if
prescribed, often at an insufficient dose
• 90% of pts with gout are poorly controlled or
improperly managed
• Full patient education increased adherence to
ULT, leading to a high rate (92%) of effectively
treated patients at 12 months
Rheumatology (Oxford) 2013;52:1623–9; Ann Rheum Dis 2012;71:1490–5.
Ann Rheum Dis 2013;72:826–30; F1000Res. 2017 Mar 10;6:247
Overarching principles
• Patient education: GOUT IS CURABLE
• Every person with gout should receive
advice regarding lifestyle:
– Weight loss
– Avoidance of alcohol (especially beer and spirits)
and sugar-sweetened drinks, heavy meals and
excessive intake of meat and seafood.
(Low-fat dairy products, coffee, Vit C are
protective)
• Regular exercise
Dietary Factors That Can
Contribute to Hyperuricemia
• Animal sources:
• • Red meat (beef, lamb, pork)
• • Meat extracts (broth, gravy)
• • Organ meats (e.g., sweet breads, liver, and
kidney)
• • Seafood with high-purine content (e.g.,
sardines, anchovies, shellfish (shrimp, lobster)
• Alcohol
• High-fructose corn syrup–sweetened beverages,
sodas
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
N Engl J Med 2004;350:1093-103.
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Arthritis Rheum. 2007 Jun;56(6):2049-55
45,869 men
757 cases of gou
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Comorbidities
• Every person with gout
should be systematically
screened for associated
comorbidities and
cardiovascular risk
factors:
(Hyperuricaemia and/or
gout are independent
risk factors for these
conditions and for
death due to CV causes)
– Renal impairment
– Coronary heart disease
– Heart failure
– Stroke
– Peripheral arterial
disease
– Obesity
– Hyperlipidaemia
– Hypertension
– Diabetes
– Smoking,
HR for total and CV mortality: 1.42 and 1.58
QJM. 2013;106(7):647-58
Metabolic syndrome
• Amongst individuals with gout the prevalence
of metabolic syndrome IS 62.8%, compared
with 25.4% among those without gout (age-
adjusted and sex-adjusted OR = 3.05, 95% CI =
2.01, 4.61).
Arthritis Rheum. 2007;57(1):109-15
Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE
Treatment of acute flares
• Acute flares of gout should be treated as early
as possible.
• Pill in pocket approach: Patient to self-
medicate at the first warning symptoms.
• The choice of drug (s) should be based on:
– presence of contraindications
– patient’s previous experience with treatments
– time of initiation after flare onset
– number and type of joint(s) involved.
Conventional Teaching
• Acute gout flares are treated with 1 tablet of
colchicine hourly until the patient develops
diarrhea or gets better.
22
23
AGREE study: Acute Gout Flare
Receiving ColchicinE Evaluation
• High vs. Low Dose Colchicine for Gout Flare
• Randomized, double-blind, placebo-controlled
study
• Low dose colchicine (1.8mg total over 1 h) 3 tabs
• High dose colchicine (4.8mg total over 6 h) 8 tabs
• Primary end point: >50% pain reduction in 24
hours
• 184 patients intent-to-treat analysis
Terkeltaub, RA., et al. Arthritis Rheum 2010.
24
AGREE study: Acute Gout Flare
Receiving ColchicinE Evaluation
Colchicine
Dose
% >50%
reduction in
pain
P value vs.
placebo
Adverse
Event Rate
% needing
rescue
medications
High dose 32.7% 0.034 76.9% 34.6%
Low dose 37.8% 0.005 36.5% 31.1%
Placebo 15.5% n/a 27.1% 50.0%
Adverse Events High Dose Low Dose Placebo
All GI Events 76.9 25.7 20.3
Diarrhea 76.9 23.0 13.6
Nausea 17.3 4.1 5.1
Vomiting 17.3 0 0
Terkeltaub, RA., et al. Arthritis Rheum 2010.
Acute flares
Options:
• Colchicine (within 12 hours of flare onset) at
a loading dose of 1 mg followed 1 hour later
by 0.5 mg
• NSAID (plus proton pump inhibitors if
appropriate)
• Oral corticosteroid (30–35 mg/day of
prednisolone for 3–5 days)
• Joint aspiration and injection of
corticosteroids
• IL-1 blocker
IL-1 Blocker
• In patients with frequent flares and
contraindications to colchicine, NSAIDs and
corticosteroids, IL-1 blockers should be
considered for treating flares.
• Current infection is a contraindication to the
use of IL-1 blockers.
Ann Rheum Dis
2012;71:1839–48.
Multiple steps in the inflammatory cascade initiated by
monosodium urate (MSU) crystals.
Alexander So, and Nathalie Busso Ann Rheum Dis 2009;68:1517-1519
Figure 2. Activation of the NLRP3 inflammasome and the production IL-1β.
Igel TF, Krasnokutsky S and Pillinger MH 2017 [version 1; referees: 2 approved] F1000Research
2017, 6:247 (doi: 10.12688/f1000research.9402.1)
Flare Prophylaxis
• Prophylaxis recommended during the first 6
months of ULT.
• Recommended prophylactic treatment:
– Colchicine, 0.5–1 mg/day
– If colchicine not tolerated or contraindicated,
NSAIDs at low dosage, e.g. naproxen 250 mg bid
Urate lowering therapy
• ULT indicated from first presentation in.
– Recurrent flares
– Tophi
– Urate arthropathy and/or renal stones
– Patients presenting at a young age (<40 years)
– Very high SUA level (>8.0 mg/dL; 480 mmol/L)
– Comorbidities (renal impairment, hypertension,
ischaemic heart disease, heart failure)
Am J Med. 1987;82:421-426
ULT: target
• TREAT TO TARGET: SUA <6 mg/dL (360 mmol/L)
• Lower SUA target (<5 mg/dL; 300 mmol/L) for
patients with severe gout
• SUA level <3 mg/dL not recommended
• All ULTs to be started at a low dose and then
titrated upwards
• SUA <6 mg/dL (360 mmol/L) should be
maintained lifelong.
33
Pathophysiology
33
hypoxanthine Uric acidxanthine
XO XO
XO=xanthine oxidase
Allopurinol and febuxostat inhibit
xanthine oxidase and block uric acid
formation
Markel A. IMAJ, 2005.
34
Oxypurinol
• Oxypurinol, allopurinol metabolite, cleared by kidney and
accumulates in patients with renal failure
• Increased oxypurinol related to risk of allopurinol
hypersensitivity syndrome
allopurinol oxypurinol
Xanthine
Oxidase
Stevens-Johnson
Syndrome
Allopurinol
Hypersensitivity
Syndrome
Toxic Epidermal
Necrolysis
35
Allopurinol and Renal
Insufficiency
• 1984 Hande, et al published “Severe
allopurinol toxicity: Description and
guidelines for prevention in patients with
renal insufficiency”
– “Avoidance of allopurinol or use of reduced doses in
patients with renal insufficiency according to proposed
guidelines should be adequate to inhibit uric acid
production in most patients and may reduce the
incidence of life-threatening allopurinol toxicity.”
Hande KR, et al. Am J Med, 1984.
CrCl (mL/min)
Maintenance Dose of
Allopurinol
0 100mg every 3d
10 100mg every 2d
20 100mg
40 150mg
60 200mg
80 250mg
100 300mg
120 350mg
140 400mg
Maintenance Doses of Allopurinol
for Adults based on CrCl
36Hande KR, et al. Am J Med, 1984.
Stage 1 renal damage with normal GFR
(GFR > 90 ml/min)
Stage 2 Mild CKD (GFR = 60-89 ml/min)
Stage 3 Modererate CKD (GFR = 30-59 ml/min)
Stage 4 Severe CKD (GFR = 15-29 ml/min)
Stage 5 End Stage CKD (GFR <15 ml/min)
Allopurinol Hypersensitivity Syndrome
• 2% of all allopurinol users develop cutaneous rash
• Severe cutaneous adverse drug reactions (SCARs) including
Stevens-Johnson syndrome (SJS) and toxic epidermal
necrolysis (TEN) rare but serious.
• 20% mortality rate
• Strong association with HLA-B*58.01 (>100-fold) risk
• Life threatening toxicity: vasculitis, rash, eosinophilia,
hepatitis, progressive renal failure
• Treatment: early recognition, withdrawal of drug, supportive
care
– Steroids, N-acetyl-cysteine, dialysis prn
37
Markel A. IMAJ, 2005.
Terkeltaub RA, in Primer on the Rheumatic Disease, 13th ed. 2008.
Allopurinol in CRF
• 1st T2T RCT
• Gout patients on CrCL-
based allopurinol dose
for ≥1 month and SU
≥6 mg/dL recruited
• Randomised to
continue current dose
(control= 93) or
allopurinol dose
escalation (n=90) for 12
months.
• At month 12, 32% of
controls and 69% in the
dose escalation had SU
<6 mg/dL.
• There were 43 serious
AEs in 25 controls and
35 events in 22 dose
escalation participants.
Ann Rheum Dis. 2017 Mar 17. pii:
annrheumdis-2016-210872. doi:
10.1136/annrheumdis-2016-210872.
[Epub ahead of print]
ULT
• With normal RFT, start allopurinol at 100
mg/day
• Increase by 100 mg increments every 2–4
weeks if required.
• If SUA target not reached, switch to febuxostat
+ uricosuric
40
Allopurinol vs. Febuxostat
Allopurinol Febuxostat (Uloric)
FDA-approved 1966 FDA-approved 2009
Purine-selective XO Inhibitor Non-Purine Selective XO
Inhibitor
Prevents uric acid production Prevents uric acid production
Renal Metabolism Liver Metabolism
Uricosurics
• Uricosurics are recommended, where
available, alone or in combination with
allopurinol in patients without proper control
with allopurinol alone
• Benzbromarone (50–200 mg/day) is a more
potent uricosuric as compared with
probenecid (1–2 g/day).
Lesinurad
• Uricosuric
• Uric Acid Transporter 1 (URAT1) Inhibitor
• URAT1 is responsible for the majority of the
reabsorption of filtered uric acid from the
renal tubular lumen
Perez-Ruiz F, et al. Ann Rheum Dis 2016;0:1–7
Adapted from Rees, F. et al. (2014) Nat Rev Rheumatol 10: 271–283.
Trials
• The regulatory approval of lesinurad is based on
three RCTs - CLEAR 1, CLEAR 2, and CRYSTAL
• Arthritis Rheum 2014;66:3533-4.
• Ann Rheum Dis 2015;74 Suppl 2:778
FDA approval Dec 2015
European approval 2016
Effect of Lesinurad in Allopurinol-
refractory Gout
• Investigated in combination with allopurinol or with
febuxostat versus either agent in monotherapy
– Doses studied: 200 mg: in combination with stable
allopurinol 200 – 600 and febuxostat 40 and 80
– Lesinurad was found to be:
• Very effective at achieving normal SUA levels in combination
with allopurinol or febuxostat
– Febuxostat combination better than the allopurinol combination
– Patients receiving concomitant HCTZ fared better than those not
receiving HCTZ
Perez-Ruiz F, et al. Ann Rheum Dis 2016;0:1–7
Clinical Application
• Dosing:
– 200mg by mouth daily with XAO
• Indications:
– Only in combination with a xanthine oxidase
inhibitor for the treatment of hyperuricemia
associated with gout
• Place in therapy:
– Patients who have not achieved target serum
uric acid levels with a xanthine oxidase inhibitor
alone
Contraindications
• Severe renal impairment, end stage renal
disease, and kidney transplant recipients
• Avoid in patients with CrCl < 45mL/min
• Can cause serum creatinine elevations
(generally reversible) – periodically monitor
• Tumor lysis syndrome or Lesch-Nyhan
syndrome
Severe and iatrogenic gout:
Pegloticase
• In patients with severe debilitating chronic
tophaceous gout and poor QOL, in whom the
SUA target cannot be reached with any other
available drug at the maximal dosage
(including combinations), pegloticase is
indicated.
• 8 mg, every 2 weeks
• Allergic reactions in 25%
Other drugs and gout
• Diuretics
• Antihypertensives
• Aspirin
Diuretics
• 91,530 cases of gout
• Loop and thiazide diuretics increase risk: OR
2.64, 1.70
• Calcium channel blockers or losartan
attenuate risk
Arthritis Rheumatol. 2014 Feb;66(2):427.
Antihypertensives
• RR of incident gout with current use of
antihypertensive drugs(n = 29,138)
• RR
– 0.87 for calcium channel blockers
– 0.81 for losartan
– 2.36 for diuretics
– 1.48 for Beta blockers
– 1.24 for ACE inhibitors
– 1.29 for non-losartan ARBs
BMJ. 2012 Jan 12;344
Gout with diuretics
• When gout occurs in a patient receiving loop
or thiazide diuretics, substitute the diuretic if
possible; for hypertension, consider losartan
or calcium channel blockers; for
hyperlipidaemia, consider a statin or
fenofibrate.
Take Home Points
• Patient education and partnership
• Advice regarding diet, weight loss, exercise
• Screening for co-morbidities
• Treatment of acute flare
• ULT and flare prophylaxis – treat to target
• Colchicine has FDA-approved dosing guidelines for chronic
kidney disease
• Allopurinol doses above recommended CrCl-based dose is
effective with minimal adverse effect
• Febuxostat is an excellent alternative for patients with renal
insufficiency
• Lesinurad is new approved uricosuric
56
Thank You

More Related Content

What's hot

Gout cdm2 2014_class version(1)
Gout cdm2 2014_class version(1)Gout cdm2 2014_class version(1)
Gout cdm2 2014_class version(1)Natalie Burman
 
pathology & treatment of Gout
 pathology & treatment of Gout pathology & treatment of Gout
pathology & treatment of GoutGULAM NAVI AZAD
 
Sabah ( Malaysia) rheumatology update gout 2016
Sabah ( Malaysia)  rheumatology update gout 2016Sabah ( Malaysia)  rheumatology update gout 2016
Sabah ( Malaysia) rheumatology update gout 2016DrAlan83
 
Gout - all you need for primary care
Gout - all you need for primary careGout - all you need for primary care
Gout - all you need for primary careRonan Kavanagh
 
Gout presentation
Gout presentationGout presentation
Gout presentationKochi Chia
 
Febuxostat for treatment of chronic gout
Febuxostat for treatment of chronic goutFebuxostat for treatment of chronic gout
Febuxostat for treatment of chronic goutChoying Chen
 
Drug Treatment Of Gout
Drug Treatment Of GoutDrug Treatment Of Gout
Drug Treatment Of GoutDr Shah Murad
 
Febuxostat vs Allopurinol.
Febuxostat vs Allopurinol. Febuxostat vs Allopurinol.
Febuxostat vs Allopurinol. microgeek
 
Management of acute and recurrent gout
Management of acute and recurrent goutManagement of acute and recurrent gout
Management of acute and recurrent goutAhmed Abouelela
 
pharmacotherapy of gout
pharmacotherapy of goutpharmacotherapy of gout
pharmacotherapy of goutfouziyabegum2
 
Challenges in the management of chronic gout
Challenges in the management of chronic goutChallenges in the management of chronic gout
Challenges in the management of chronic goutJames Wei 魏正宗
 
Metabolic bone diseases for students
Metabolic bone diseases for studentsMetabolic bone diseases for students
Metabolic bone diseases for studentsUsama Ragab
 
Febuxostat medical slides
Febuxostat medical slidesFebuxostat medical slides
Febuxostat medical slidesFaraz Farishta
 

What's hot (20)

Gout cdm2 2014_class version(1)
Gout cdm2 2014_class version(1)Gout cdm2 2014_class version(1)
Gout cdm2 2014_class version(1)
 
pathology & treatment of Gout
 pathology & treatment of Gout pathology & treatment of Gout
pathology & treatment of Gout
 
Sabah ( Malaysia) rheumatology update gout 2016
Sabah ( Malaysia)  rheumatology update gout 2016Sabah ( Malaysia)  rheumatology update gout 2016
Sabah ( Malaysia) rheumatology update gout 2016
 
Gout - all you need for primary care
Gout - all you need for primary careGout - all you need for primary care
Gout - all you need for primary care
 
Gout presentation
Gout presentationGout presentation
Gout presentation
 
Gout management
Gout managementGout management
Gout management
 
gout
goutgout
gout
 
Febuxostat for treatment of chronic gout
Febuxostat for treatment of chronic goutFebuxostat for treatment of chronic gout
Febuxostat for treatment of chronic gout
 
Drug Treatment Of Gout
Drug Treatment Of GoutDrug Treatment Of Gout
Drug Treatment Of Gout
 
Gout by mohammad nour alsaeed
Gout by mohammad nour alsaeedGout by mohammad nour alsaeed
Gout by mohammad nour alsaeed
 
Gout
Gout Gout
Gout
 
Febuxostat vs Allopurinol.
Febuxostat vs Allopurinol. Febuxostat vs Allopurinol.
Febuxostat vs Allopurinol.
 
Management of acute and recurrent gout
Management of acute and recurrent goutManagement of acute and recurrent gout
Management of acute and recurrent gout
 
pharmacotherapy of gout
pharmacotherapy of goutpharmacotherapy of gout
pharmacotherapy of gout
 
Gouty arthritis - NOTES
Gouty arthritis - NOTESGouty arthritis - NOTES
Gouty arthritis - NOTES
 
Challenges in the management of chronic gout
Challenges in the management of chronic goutChallenges in the management of chronic gout
Challenges in the management of chronic gout
 
Metabolic bone diseases for students
Metabolic bone diseases for studentsMetabolic bone diseases for students
Metabolic bone diseases for students
 
Febuxostat medical slides
Febuxostat medical slidesFebuxostat medical slides
Febuxostat medical slides
 
Addison disease
Addison diseaseAddison disease
Addison disease
 
Gout
GoutGout
Gout
 

Similar to Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE

Colin Tench Gout treat to target .pptx
Colin Tench  Gout treat to target .pptxColin Tench  Gout treat to target .pptx
Colin Tench Gout treat to target .pptxSabinParajuli7
 
SLE: present guidelines and consensus
SLE: present guidelines and consensusSLE: present guidelines and consensus
SLE: present guidelines and consensusVishal Golay
 
Immunosuppression immunomodulation
Immunosuppression immunomodulationImmunosuppression immunomodulation
Immunosuppression immunomodulationFarragBahbah
 
acute renal failure.ppt
acute renal failure.pptacute renal failure.ppt
acute renal failure.pptMsccMohamed
 
Lupus landmark trials
Lupus landmark trialsLupus landmark trials
Lupus landmark trialsSourabh Gupta
 
Indications of proton pump inhibitors
Indications of proton pump inhibitorsIndications of proton pump inhibitors
Indications of proton pump inhibitorsSamir Haffar
 
Landmark trial in lupus.pptx
Landmark trial in lupus.pptxLandmark trial in lupus.pptx
Landmark trial in lupus.pptxRitasman Baisya
 
FSGS-Sparsentan.pptx
FSGS-Sparsentan.pptxFSGS-Sparsentan.pptx
FSGS-Sparsentan.pptxssuseree565d
 
LUPUS NEPHRITIS MANAGEMENT.pptx
LUPUS NEPHRITIS MANAGEMENT.pptxLUPUS NEPHRITIS MANAGEMENT.pptx
LUPUS NEPHRITIS MANAGEMENT.pptxSuperwomanK
 
Management of Lupus Nephritis
Management of Lupus NephritisManagement of Lupus Nephritis
Management of Lupus Nephritismukkukiran
 
Management of pulmonary artery hypertension
Management of pulmonary artery hypertensionManagement of pulmonary artery hypertension
Management of pulmonary artery hypertensionAdityaNag11
 
SBP (National Hepatic Institute)
SBP (National Hepatic Institute)SBP (National Hepatic Institute)
SBP (National Hepatic Institute)Mohamed Moustafa
 
sepsis and septic shock guidelines[12585].pptx
sepsis and septic shock  guidelines[12585].pptxsepsis and septic shock  guidelines[12585].pptx
sepsis and septic shock guidelines[12585].pptxalmawali10
 
sepsis and septic shock guidelines[12585].pptx
sepsis and septic shock  guidelines[12585].pptxsepsis and septic shock  guidelines[12585].pptx
sepsis and septic shock guidelines[12585].pptxalmawali10
 
Lupus nephritis 2012
Lupus nephritis 2012Lupus nephritis 2012
Lupus nephritis 2012Amit Agrawal
 

Similar to Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE (20)

Colin Tench Gout treat to target .pptx
Colin Tench  Gout treat to target .pptxColin Tench  Gout treat to target .pptx
Colin Tench Gout treat to target .pptx
 
SLE: present guidelines and consensus
SLE: present guidelines and consensusSLE: present guidelines and consensus
SLE: present guidelines and consensus
 
Immunosuppression immunomodulation
Immunosuppression immunomodulationImmunosuppression immunomodulation
Immunosuppression immunomodulation
 
acute renal failure.ppt
acute renal failure.pptacute renal failure.ppt
acute renal failure.ppt
 
Lupus landmark trials
Lupus landmark trialsLupus landmark trials
Lupus landmark trials
 
Presentation nsaids ams
Presentation nsaids amsPresentation nsaids ams
Presentation nsaids ams
 
Indications of proton pump inhibitors
Indications of proton pump inhibitorsIndications of proton pump inhibitors
Indications of proton pump inhibitors
 
Landmark trial in lupus.pptx
Landmark trial in lupus.pptxLandmark trial in lupus.pptx
Landmark trial in lupus.pptx
 
FSGS-Sparsentan.pptx
FSGS-Sparsentan.pptxFSGS-Sparsentan.pptx
FSGS-Sparsentan.pptx
 
LUPUS NEPHRITIS MANAGEMENT.pptx
LUPUS NEPHRITIS MANAGEMENT.pptxLUPUS NEPHRITIS MANAGEMENT.pptx
LUPUS NEPHRITIS MANAGEMENT.pptx
 
16 Gout.pptx
16 Gout.pptx16 Gout.pptx
16 Gout.pptx
 
Pharmacotherapy of Gout.pptx
Pharmacotherapy of Gout.pptxPharmacotherapy of Gout.pptx
Pharmacotherapy of Gout.pptx
 
Management of Lupus Nephritis
Management of Lupus NephritisManagement of Lupus Nephritis
Management of Lupus Nephritis
 
Non resistant tuberculosis
Non resistant tuberculosisNon resistant tuberculosis
Non resistant tuberculosis
 
Management of pulmonary artery hypertension
Management of pulmonary artery hypertensionManagement of pulmonary artery hypertension
Management of pulmonary artery hypertension
 
SBP (National Hepatic Institute)
SBP (National Hepatic Institute)SBP (National Hepatic Institute)
SBP (National Hepatic Institute)
 
sepsis and septic shock guidelines[12585].pptx
sepsis and septic shock  guidelines[12585].pptxsepsis and septic shock  guidelines[12585].pptx
sepsis and septic shock guidelines[12585].pptx
 
sepsis and septic shock guidelines[12585].pptx
sepsis and septic shock  guidelines[12585].pptxsepsis and septic shock  guidelines[12585].pptx
sepsis and septic shock guidelines[12585].pptx
 
PUD.pptx
PUD.pptxPUD.pptx
PUD.pptx
 
Lupus nephritis 2012
Lupus nephritis 2012Lupus nephritis 2012
Lupus nephritis 2012
 

More from University Hospital Sharjah (7)

About University Hospital Sharjah
About University Hospital SharjahAbout University Hospital Sharjah
About University Hospital Sharjah
 
Healthy food
Healthy food  Healthy food
Healthy food
 
Arabic for non arabic speakers
Arabic for non arabic speakersArabic for non arabic speakers
Arabic for non arabic speakers
 
New initiative Q 1
New initiative Q 1New initiative Q 1
New initiative Q 1
 
Chemical Hazards !!
Chemical Hazards !!Chemical Hazards !!
Chemical Hazards !!
 
Cochlear Implants in Children.
Cochlear Implants in Children.Cochlear Implants in Children.
Cochlear Implants in Children.
 
World Prematurity Day 2014 : Dr Hakam Yaseen
World Prematurity Day 2014 : Dr Hakam YaseenWorld Prematurity Day 2014 : Dr Hakam Yaseen
World Prematurity Day 2014 : Dr Hakam Yaseen
 

Recently uploaded

Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)bishwabandhuniraula
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdfDolisha Warbi
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborHealth Catalyst
 
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdfCompliatric Where Compliance Happens
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinicsnetraangadi2
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsNeha Sharma
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsIris Thiele Isip-Tan
 
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....sharyurangari111
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychologyshantisphysio
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLyons Health
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementIris Thiele Isip-Tan
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadAlex Clapson
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha KewatNehaKewat
 
Introduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin BenefitsIntroduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin Benefitssahilgabhane29
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxMUKESH PADMANABHAN
 
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11crzljavier
 

Recently uploaded (20)

Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)
 
Painting Rats White Angers Them to No End
Painting Rats White Angers Them to No EndPainting Rats White Angers Them to No End
Painting Rats White Angers Them to No End
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
 
Three Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and LaborThree Keys to a Successful Margin: Charges, Costs, and Labor
Three Keys to a Successful Margin: Charges, Costs, and Labor
 
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinics
 
Annual Training
Annual TrainingAnnual Training
Annual Training
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common Locations
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
 
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....
Toothpaste for bleeding gums and sensitive teeth. Teeth whitening, Mouthwash....
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychology
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes Management
 
SCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATIONSCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATION
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion instead
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
 
Introduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin BenefitsIntroduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin Benefits
 
person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptx
 
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
 

Gout 2017 by Prof. Professor Sukhbir Uppal Consultant in Medicine/Rheumatology, University Hospital Sharjah, UAE

  • 1. Welcome to University Hospital Sharjah Treating gout with clinical guidelines Professor Sukhbir Uppal Consultant in Medicine/Rheumatology MBBS,MD, FRCP(UK), FACR (USA) University Hospital Sharjah, UAE
  • 2. Ann Rheum Dis. 2017 Jan;76(1):29-42
  • 3. Aims and objectives • Using the 2016 Eular guidelines as a framework, this presentation aims to achieve the following objectives: – Patient education – Screening for co-morbidities – Flare treatment and prophylaxis – Urate lowering therapy – Management of asymptomatic hyperuricemia
  • 4. Introduction • New drugs and new evidence concerning the use of established treatments have become available over the last 10 years for the management of gout.
  • 5. Rheum Dis Clin North Am. 2014 May; 40(2): 155–175. Increasing incidence of gout in men and women with serum urate level
  • 7. Barriers • Recent studies report that less than half of the patients with gout receive ULT , and if prescribed, often at an insufficient dose • 90% of pts with gout are poorly controlled or improperly managed • Full patient education increased adherence to ULT, leading to a high rate (92%) of effectively treated patients at 12 months Rheumatology (Oxford) 2013;52:1623–9; Ann Rheum Dis 2012;71:1490–5. Ann Rheum Dis 2013;72:826–30; F1000Res. 2017 Mar 10;6:247
  • 8. Overarching principles • Patient education: GOUT IS CURABLE • Every person with gout should receive advice regarding lifestyle: – Weight loss – Avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood. (Low-fat dairy products, coffee, Vit C are protective) • Regular exercise
  • 9. Dietary Factors That Can Contribute to Hyperuricemia • Animal sources: • • Red meat (beef, lamb, pork) • • Meat extracts (broth, gravy) • • Organ meats (e.g., sweet breads, liver, and kidney) • • Seafood with high-purine content (e.g., sardines, anchovies, shellfish (shrimp, lobster) • Alcohol • High-fructose corn syrup–sweetened beverages, sodas
  • 11. N Engl J Med 2004;350:1093-103.
  • 15. Arthritis Rheum. 2007 Jun;56(6):2049-55 45,869 men 757 cases of gou
  • 18. Comorbidities • Every person with gout should be systematically screened for associated comorbidities and cardiovascular risk factors: (Hyperuricaemia and/or gout are independent risk factors for these conditions and for death due to CV causes) – Renal impairment – Coronary heart disease – Heart failure – Stroke – Peripheral arterial disease – Obesity – Hyperlipidaemia – Hypertension – Diabetes – Smoking, HR for total and CV mortality: 1.42 and 1.58 QJM. 2013;106(7):647-58
  • 19. Metabolic syndrome • Amongst individuals with gout the prevalence of metabolic syndrome IS 62.8%, compared with 25.4% among those without gout (age- adjusted and sex-adjusted OR = 3.05, 95% CI = 2.01, 4.61). Arthritis Rheum. 2007;57(1):109-15
  • 21. Treatment of acute flares • Acute flares of gout should be treated as early as possible. • Pill in pocket approach: Patient to self- medicate at the first warning symptoms. • The choice of drug (s) should be based on: – presence of contraindications – patient’s previous experience with treatments – time of initiation after flare onset – number and type of joint(s) involved.
  • 22. Conventional Teaching • Acute gout flares are treated with 1 tablet of colchicine hourly until the patient develops diarrhea or gets better. 22
  • 23. 23 AGREE study: Acute Gout Flare Receiving ColchicinE Evaluation • High vs. Low Dose Colchicine for Gout Flare • Randomized, double-blind, placebo-controlled study • Low dose colchicine (1.8mg total over 1 h) 3 tabs • High dose colchicine (4.8mg total over 6 h) 8 tabs • Primary end point: >50% pain reduction in 24 hours • 184 patients intent-to-treat analysis Terkeltaub, RA., et al. Arthritis Rheum 2010.
  • 24. 24 AGREE study: Acute Gout Flare Receiving ColchicinE Evaluation Colchicine Dose % >50% reduction in pain P value vs. placebo Adverse Event Rate % needing rescue medications High dose 32.7% 0.034 76.9% 34.6% Low dose 37.8% 0.005 36.5% 31.1% Placebo 15.5% n/a 27.1% 50.0% Adverse Events High Dose Low Dose Placebo All GI Events 76.9 25.7 20.3 Diarrhea 76.9 23.0 13.6 Nausea 17.3 4.1 5.1 Vomiting 17.3 0 0 Terkeltaub, RA., et al. Arthritis Rheum 2010.
  • 25. Acute flares Options: • Colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg • NSAID (plus proton pump inhibitors if appropriate) • Oral corticosteroid (30–35 mg/day of prednisolone for 3–5 days) • Joint aspiration and injection of corticosteroids • IL-1 blocker
  • 26. IL-1 Blocker • In patients with frequent flares and contraindications to colchicine, NSAIDs and corticosteroids, IL-1 blockers should be considered for treating flares. • Current infection is a contraindication to the use of IL-1 blockers. Ann Rheum Dis 2012;71:1839–48.
  • 27. Multiple steps in the inflammatory cascade initiated by monosodium urate (MSU) crystals. Alexander So, and Nathalie Busso Ann Rheum Dis 2009;68:1517-1519
  • 28. Figure 2. Activation of the NLRP3 inflammasome and the production IL-1β. Igel TF, Krasnokutsky S and Pillinger MH 2017 [version 1; referees: 2 approved] F1000Research 2017, 6:247 (doi: 10.12688/f1000research.9402.1)
  • 29. Flare Prophylaxis • Prophylaxis recommended during the first 6 months of ULT. • Recommended prophylactic treatment: – Colchicine, 0.5–1 mg/day – If colchicine not tolerated or contraindicated, NSAIDs at low dosage, e.g. naproxen 250 mg bid
  • 30. Urate lowering therapy • ULT indicated from first presentation in. – Recurrent flares – Tophi – Urate arthropathy and/or renal stones – Patients presenting at a young age (<40 years) – Very high SUA level (>8.0 mg/dL; 480 mmol/L) – Comorbidities (renal impairment, hypertension, ischaemic heart disease, heart failure)
  • 31. Am J Med. 1987;82:421-426
  • 32. ULT: target • TREAT TO TARGET: SUA <6 mg/dL (360 mmol/L) • Lower SUA target (<5 mg/dL; 300 mmol/L) for patients with severe gout • SUA level <3 mg/dL not recommended • All ULTs to be started at a low dose and then titrated upwards • SUA <6 mg/dL (360 mmol/L) should be maintained lifelong.
  • 33. 33 Pathophysiology 33 hypoxanthine Uric acidxanthine XO XO XO=xanthine oxidase Allopurinol and febuxostat inhibit xanthine oxidase and block uric acid formation Markel A. IMAJ, 2005.
  • 34. 34 Oxypurinol • Oxypurinol, allopurinol metabolite, cleared by kidney and accumulates in patients with renal failure • Increased oxypurinol related to risk of allopurinol hypersensitivity syndrome allopurinol oxypurinol Xanthine Oxidase Stevens-Johnson Syndrome Allopurinol Hypersensitivity Syndrome Toxic Epidermal Necrolysis
  • 35. 35 Allopurinol and Renal Insufficiency • 1984 Hande, et al published “Severe allopurinol toxicity: Description and guidelines for prevention in patients with renal insufficiency” – “Avoidance of allopurinol or use of reduced doses in patients with renal insufficiency according to proposed guidelines should be adequate to inhibit uric acid production in most patients and may reduce the incidence of life-threatening allopurinol toxicity.” Hande KR, et al. Am J Med, 1984.
  • 36. CrCl (mL/min) Maintenance Dose of Allopurinol 0 100mg every 3d 10 100mg every 2d 20 100mg 40 150mg 60 200mg 80 250mg 100 300mg 120 350mg 140 400mg Maintenance Doses of Allopurinol for Adults based on CrCl 36Hande KR, et al. Am J Med, 1984. Stage 1 renal damage with normal GFR (GFR > 90 ml/min) Stage 2 Mild CKD (GFR = 60-89 ml/min) Stage 3 Modererate CKD (GFR = 30-59 ml/min) Stage 4 Severe CKD (GFR = 15-29 ml/min) Stage 5 End Stage CKD (GFR <15 ml/min)
  • 37. Allopurinol Hypersensitivity Syndrome • 2% of all allopurinol users develop cutaneous rash • Severe cutaneous adverse drug reactions (SCARs) including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) rare but serious. • 20% mortality rate • Strong association with HLA-B*58.01 (>100-fold) risk • Life threatening toxicity: vasculitis, rash, eosinophilia, hepatitis, progressive renal failure • Treatment: early recognition, withdrawal of drug, supportive care – Steroids, N-acetyl-cysteine, dialysis prn 37 Markel A. IMAJ, 2005. Terkeltaub RA, in Primer on the Rheumatic Disease, 13th ed. 2008.
  • 38. Allopurinol in CRF • 1st T2T RCT • Gout patients on CrCL- based allopurinol dose for ≥1 month and SU ≥6 mg/dL recruited • Randomised to continue current dose (control= 93) or allopurinol dose escalation (n=90) for 12 months. • At month 12, 32% of controls and 69% in the dose escalation had SU <6 mg/dL. • There were 43 serious AEs in 25 controls and 35 events in 22 dose escalation participants. Ann Rheum Dis. 2017 Mar 17. pii: annrheumdis-2016-210872. doi: 10.1136/annrheumdis-2016-210872. [Epub ahead of print]
  • 39. ULT • With normal RFT, start allopurinol at 100 mg/day • Increase by 100 mg increments every 2–4 weeks if required. • If SUA target not reached, switch to febuxostat + uricosuric
  • 40. 40 Allopurinol vs. Febuxostat Allopurinol Febuxostat (Uloric) FDA-approved 1966 FDA-approved 2009 Purine-selective XO Inhibitor Non-Purine Selective XO Inhibitor Prevents uric acid production Prevents uric acid production Renal Metabolism Liver Metabolism
  • 41. Uricosurics • Uricosurics are recommended, where available, alone or in combination with allopurinol in patients without proper control with allopurinol alone • Benzbromarone (50–200 mg/day) is a more potent uricosuric as compared with probenecid (1–2 g/day).
  • 42. Lesinurad • Uricosuric • Uric Acid Transporter 1 (URAT1) Inhibitor • URAT1 is responsible for the majority of the reabsorption of filtered uric acid from the renal tubular lumen Perez-Ruiz F, et al. Ann Rheum Dis 2016;0:1–7
  • 43. Adapted from Rees, F. et al. (2014) Nat Rev Rheumatol 10: 271–283.
  • 44. Trials • The regulatory approval of lesinurad is based on three RCTs - CLEAR 1, CLEAR 2, and CRYSTAL • Arthritis Rheum 2014;66:3533-4. • Ann Rheum Dis 2015;74 Suppl 2:778 FDA approval Dec 2015 European approval 2016
  • 45. Effect of Lesinurad in Allopurinol- refractory Gout • Investigated in combination with allopurinol or with febuxostat versus either agent in monotherapy – Doses studied: 200 mg: in combination with stable allopurinol 200 – 600 and febuxostat 40 and 80 – Lesinurad was found to be: • Very effective at achieving normal SUA levels in combination with allopurinol or febuxostat – Febuxostat combination better than the allopurinol combination – Patients receiving concomitant HCTZ fared better than those not receiving HCTZ Perez-Ruiz F, et al. Ann Rheum Dis 2016;0:1–7
  • 46. Clinical Application • Dosing: – 200mg by mouth daily with XAO • Indications: – Only in combination with a xanthine oxidase inhibitor for the treatment of hyperuricemia associated with gout • Place in therapy: – Patients who have not achieved target serum uric acid levels with a xanthine oxidase inhibitor alone
  • 47. Contraindications • Severe renal impairment, end stage renal disease, and kidney transplant recipients • Avoid in patients with CrCl < 45mL/min • Can cause serum creatinine elevations (generally reversible) – periodically monitor • Tumor lysis syndrome or Lesch-Nyhan syndrome
  • 48. Severe and iatrogenic gout: Pegloticase • In patients with severe debilitating chronic tophaceous gout and poor QOL, in whom the SUA target cannot be reached with any other available drug at the maximal dosage (including combinations), pegloticase is indicated. • 8 mg, every 2 weeks • Allergic reactions in 25%
  • 49. Other drugs and gout • Diuretics • Antihypertensives • Aspirin
  • 50. Diuretics • 91,530 cases of gout • Loop and thiazide diuretics increase risk: OR 2.64, 1.70 • Calcium channel blockers or losartan attenuate risk Arthritis Rheumatol. 2014 Feb;66(2):427.
  • 51. Antihypertensives • RR of incident gout with current use of antihypertensive drugs(n = 29,138) • RR – 0.87 for calcium channel blockers – 0.81 for losartan – 2.36 for diuretics – 1.48 for Beta blockers – 1.24 for ACE inhibitors – 1.29 for non-losartan ARBs BMJ. 2012 Jan 12;344
  • 52. Gout with diuretics • When gout occurs in a patient receiving loop or thiazide diuretics, substitute the diuretic if possible; for hypertension, consider losartan or calcium channel blockers; for hyperlipidaemia, consider a statin or fenofibrate.
  • 53. Take Home Points • Patient education and partnership • Advice regarding diet, weight loss, exercise • Screening for co-morbidities • Treatment of acute flare • ULT and flare prophylaxis – treat to target • Colchicine has FDA-approved dosing guidelines for chronic kidney disease • Allopurinol doses above recommended CrCl-based dose is effective with minimal adverse effect • Febuxostat is an excellent alternative for patients with renal insufficiency • Lesinurad is new approved uricosuric 56