SlideShare una empresa de Scribd logo
1 de 33
Descargar para leer sin conexión
GOUT 2012:
Updates to an Old Disease
Assumptions


               “The ACR gout guidelines are designed
                  to emphasize safety and quality of
                 therapy and to reflect best practice.”

 • Correct Diagnosis
 • Consider Co-morbid conditions
 • Evaluate for Drug interactions


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.
Levels of Evidence



A   Meta-analyses
    >1 Randomized Clinical Trial



B   Single Randomized Clinical Trial
    Non-Randomized Studies

    Standards of Care
C   Case Studies
    Expert Consensus
Nomenclature (Acute)

SEVERITY (Pain VAS)

    1   2   3    4     5        6   7   8    9   10

DURATION (from onset of symptoms)


0           12             24           36

FREQUENCY (No of flares/ year)

    1   2   3    4     5        6   7   8    9   10
Nomenclature

      JOINT INVOLVEMENT
      • Few small joints

      • 1 or 2 large joints

      • Polyarthritis
         • 4 or more joints
           involving >1 region
         • 3 large joints
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
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.
ACUTE GOUT
                     a.k.a. GOUT FLARE
Self limited attack of joint inflammation
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)
Choosing an Anti-Inflammatory


                            Start
  Pain VAS     Yes
   <7/10
                     MONOTHERAPY
                             (A)
      No



                     CONSIDER
    Start
                     • Patient preference
COMBINATION
                     • Prior response to meds
 THERAPY (C)
                     • Associated co-morbids
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)
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
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)
Combination Therapy in Acute Gout

• Colchicine with NSAIDs
• Colchicine with Steroids
• IA Steroids with Colchicine/ NSAIDs/ Oral
  Steroids

• Consider topical ice application (B)
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)
Contraindications

CONDITION                       NSAIDs   Colchicine   Steroids

Chronic Kidney Disease St 3-5              
Peptic Ulcer Disease                       
Heart Failure                    
Anti-coagulants/ platelets       
Diabetes Mellitus                                       
Infection                                               
Liver Disease                              
Continuing Acute Gout Care


INADEQUATE
  RESPONSE            REVIEW the diagnosis
                Yes
 <20% in 24H          CONSIDER
or <50% after         • Shift to other drug (C)
     24H              • Combine therapy (C)
       No             • Anakinra 100 mg SC for
                        3 days (B)
                      • Canakinumab 150 mg
 COMPLETE               SC single dose (A)
TREATMENT
PROPHYLAXIS
To be started in all patients in whom
 Urate Lowering Therapy is indicated
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)
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)
URATE LOWERING
       THERAPY
Pharmacologic and Non-Pharmacologic
Diet and Lifestyle Changes




       AVOID                      LIMIT                 ENCOURAGE
Organ meats (B)           Seafood (B)                Low fat or non-fat dairy
Drinks with fructose(C)   Sweetened fruit juices (C) products (B)
Alcohol overuse (B)       Sugar (C)                  Vegetables (C)
Alcohol during an acute   Salt (C)
attack (C)
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
Checklist

COMORBIDS (C)
• Obesity                     LABORATORIES
• Alcohol intake              •   Urinalysis
• Metabolic Syndrome and      •   Renal ultrasound
  components                  •   CBC
• Kidney disease              •   Urine uric acid
• Lead intoxication               determination (C)
• Myeloprolif/ lymphoprolif       – Gout < 25 y/o
  disorders                       – Nephrolithiases

• Psoriasis
Indications for ULT

• Evidence of tophus/tophi (A)
• Frequent attacks (>2/year) (A)
• History of nephrolithiases (C)
• Chronic Kidney Disease Stage 2-5 (C)
Target Blood Uric Acid




<6 mg/dl                     <5 mg/dl
For most gout scenarios          For more durable
(if without visible tophi)   improvement and patients
           (A)                 with visible tophi (B)
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)
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
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
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
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)
Consider referring when…

•   Unclear etiology of hyperuricemia
•   Refractory gout
•   Difficulty in achieving target BUA
•   Multiple or serious AE from ULT
PHILRHEUMAJR.BLOGSPOT.COM




THANK YOU

Más contenido relacionado

La actualidad más candente

Updates to the Approach to Rheumatic Disease
Updates to the Approach to Rheumatic DiseaseUpdates to the Approach to Rheumatic Disease
Updates to the Approach to Rheumatic DiseaseSidney Erwin Manahan
 
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
 
Occult hcv infection the updated knowledge
Occult hcv infection the updated knowledge Occult hcv infection the updated knowledge
Occult hcv infection the updated knowledge Monkez M Yousif
 
Relative Blood Volume Monitoring and Applications in Dialysis
Relative Blood Volume Monitoring and Applications in DialysisRelative Blood Volume Monitoring and Applications in Dialysis
Relative Blood Volume Monitoring and Applications in DialysisChristos Argyropoulos
 
Pathophysiology and clinical management of gouty arthritis
Pathophysiology and clinical management of gouty arthritisPathophysiology and clinical management of gouty arthritis
Pathophysiology and clinical management of gouty arthritisSoujanya Pharm.D
 
Acr 2012 updates and Philippine applicability
Acr 2012 updates and Philippine applicabilityAcr 2012 updates and Philippine applicability
Acr 2012 updates and Philippine applicabilitySidney Erwin Manahan
 
ICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
 
AKI Lecture 2010
AKI Lecture 2010AKI Lecture 2010
AKI Lecture 2010Joel Topf
 
Gout and pseudo gout
Gout and pseudo gout Gout and pseudo gout
Gout and pseudo gout sabir khadka
 
Gout and Hyperuricemia
Gout and HyperuricemiaGout and Hyperuricemia
Gout and HyperuricemiaArwa M. Amin
 
How to link glucose control to cv outcomes
How to link glucose control to cv outcomesHow to link glucose control to cv outcomes
How to link glucose control to cv outcomesYichi Chen
 
Prescribing an app
Prescribing an appPrescribing an app
Prescribing an appJoel Topf
 
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...NephroTube - Dr.Gawad
 
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis C
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis CSide effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis C
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis CSamir Haffar
 

La actualidad más candente (20)

Updates to the Approach to Rheumatic Disease
Updates to the Approach to Rheumatic DiseaseUpdates to the Approach to Rheumatic Disease
Updates to the Approach to Rheumatic Disease
 
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
 
Gout management
Gout managementGout management
Gout management
 
Active and Latent TB in Patients with Rheumatic Diseases
Active and Latent TB in Patients with Rheumatic DiseasesActive and Latent TB in Patients with Rheumatic Diseases
Active and Latent TB in Patients with Rheumatic Diseases
 
Occult hcv infection the updated knowledge
Occult hcv infection the updated knowledge Occult hcv infection the updated knowledge
Occult hcv infection the updated knowledge
 
Relative Blood Volume Monitoring and Applications in Dialysis
Relative Blood Volume Monitoring and Applications in DialysisRelative Blood Volume Monitoring and Applications in Dialysis
Relative Blood Volume Monitoring and Applications in Dialysis
 
GOUT
GOUT GOUT
GOUT
 
Pathophysiology and clinical management of gouty arthritis
Pathophysiology and clinical management of gouty arthritisPathophysiology and clinical management of gouty arthritis
Pathophysiology and clinical management of gouty arthritis
 
Acr 2012 updates and Philippine applicability
Acr 2012 updates and Philippine applicabilityAcr 2012 updates and Philippine applicability
Acr 2012 updates and Philippine applicability
 
GOUT
GOUTGOUT
GOUT
 
ICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal FailureICN VIctoria: John Botha on Critical Care Renal Failure
ICN VIctoria: John Botha on Critical Care Renal Failure
 
AKI Lecture 2010
AKI Lecture 2010AKI Lecture 2010
AKI Lecture 2010
 
Gout and pseudo gout
Gout and pseudo gout Gout and pseudo gout
Gout and pseudo gout
 
Gout and Hyperuricemia
Gout and HyperuricemiaGout and Hyperuricemia
Gout and Hyperuricemia
 
Crystal induced arthritis - Carlin
Crystal induced arthritis - CarlinCrystal induced arthritis - Carlin
Crystal induced arthritis - Carlin
 
Dialysis in acute kidney injury
Dialysis in acute kidney injuryDialysis in acute kidney injury
Dialysis in acute kidney injury
 
How to link glucose control to cv outcomes
How to link glucose control to cv outcomesHow to link glucose control to cv outcomes
How to link glucose control to cv outcomes
 
Prescribing an app
Prescribing an appPrescribing an app
Prescribing an app
 
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...
Cardiorenal Syndrome (Clinical Implications and Treatment Strategies) - Dr. G...
 
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis C
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis CSide effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis C
Side effects of Peg-Interferon & Ribavirin in treatment of chronic hepatitis C
 

Similar a Gout 2012: Updates to an Old Disease

AKI IN CIRRHOSIS 1.pptx
AKI IN CIRRHOSIS 1.pptxAKI IN CIRRHOSIS 1.pptx
AKI IN CIRRHOSIS 1.pptxDrHarsh Saxena
 
Gout - what should I be doing in Primary Care?
Gout - what should I be doing in Primary Care?Gout - what should I be doing in Primary Care?
Gout - what should I be doing in Primary Care?pcsciences
 
MedReg+1 Matthews Gastro
MedReg+1 Matthews GastroMedReg+1 Matthews Gastro
MedReg+1 Matthews GastroMedReg+1
 
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
 
Ulcerative Colitis: Case Presentation & Disease Overview
Ulcerative Colitis: Case Presentation & Disease OverviewUlcerative Colitis: Case Presentation & Disease Overview
Ulcerative Colitis: Case Presentation & Disease Overviewfarah al souheil
 
GI and LIVER SE of Common Drugs
GI and LIVER SE of Common DrugsGI and LIVER SE of Common Drugs
GI and LIVER SE of Common DrugsChernHaoChong
 
SBP (National Hepatic Institute)
SBP (National Hepatic Institute)SBP (National Hepatic Institute)
SBP (National Hepatic Institute)Mohamed Moustafa
 
Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015Jon Sweet
 
Sabah ( Malaysia) rheumatology update gout 2016
Sabah ( Malaysia)  rheumatology update gout 2016Sabah ( Malaysia)  rheumatology update gout 2016
Sabah ( Malaysia) rheumatology update gout 2016DrAlan83
 
Gout medications zagazig 2019
Gout medications zagazig 2019 Gout medications zagazig 2019
Gout medications zagazig 2019 SafwatElaraby
 
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
 
Management of hyperemesis gravidarum rcog 2016
Management of hyperemesis gravidarum  rcog 2016Management of hyperemesis gravidarum  rcog 2016
Management of hyperemesis gravidarum rcog 2016Dr Meenakshi Sharma
 
Gout and Hyperuricemia.pptx
Gout and Hyperuricemia.pptxGout and Hyperuricemia.pptx
Gout and Hyperuricemia.pptxjiregna5
 
Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014Jon Sweet
 
Gastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeGastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeApolloGleaneagls
 
Management of cirrhosis for improving survival
Management of cirrhosis for improving survivalManagement of cirrhosis for improving survival
Management of cirrhosis for improving survivalMahendra Debbarma
 
acute pancreatitis.pptx
acute pancreatitis.pptxacute pancreatitis.pptx
acute pancreatitis.pptxManoj Aryal
 
Contrast Induce Nephropathy
Contrast Induce NephropathyContrast Induce Nephropathy
Contrast Induce NephropathyZiyad Salih
 

Similar a Gout 2012: Updates to an Old Disease (20)

AKI IN CIRRHOSIS 1.pptx
AKI IN CIRRHOSIS 1.pptxAKI IN CIRRHOSIS 1.pptx
AKI IN CIRRHOSIS 1.pptx
 
Gout - what should I be doing in Primary Care?
Gout - what should I be doing in Primary Care?Gout - what should I be doing in Primary Care?
Gout - what should I be doing in Primary Care?
 
MedReg+1 Matthews Gastro
MedReg+1 Matthews GastroMedReg+1 Matthews Gastro
MedReg+1 Matthews Gastro
 
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
 
Ulcerative Colitis: Case Presentation & Disease Overview
Ulcerative Colitis: Case Presentation & Disease OverviewUlcerative Colitis: Case Presentation & Disease Overview
Ulcerative Colitis: Case Presentation & Disease Overview
 
GI and LIVER SE of Common Drugs
GI and LIVER SE of Common DrugsGI and LIVER SE of Common Drugs
GI and LIVER SE of Common Drugs
 
SBP (National Hepatic Institute)
SBP (National Hepatic Institute)SBP (National Hepatic Institute)
SBP (National Hepatic Institute)
 
Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015Hospital Medicine Update, VA ACP Meeting 2015
Hospital Medicine Update, VA ACP Meeting 2015
 
Sabah ( Malaysia) rheumatology update gout 2016
Sabah ( Malaysia)  rheumatology update gout 2016Sabah ( Malaysia)  rheumatology update gout 2016
Sabah ( Malaysia) rheumatology update gout 2016
 
Gout medications zagazig 2019
Gout medications zagazig 2019 Gout medications zagazig 2019
Gout medications zagazig 2019
 
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
 
2ry htn
2ry htn2ry htn
2ry htn
 
Management of hyperemesis gravidarum rcog 2016
Management of hyperemesis gravidarum  rcog 2016Management of hyperemesis gravidarum  rcog 2016
Management of hyperemesis gravidarum rcog 2016
 
Gout and Hyperuricemia.pptx
Gout and Hyperuricemia.pptxGout and Hyperuricemia.pptx
Gout and Hyperuricemia.pptx
 
Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014Hospital Medicine Pearls, VA ACP Meeting 2014
Hospital Medicine Pearls, VA ACP Meeting 2014
 
Gastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeGastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal Syndrome
 
Management of cirrhosis for improving survival
Management of cirrhosis for improving survivalManagement of cirrhosis for improving survival
Management of cirrhosis for improving survival
 
acute pancreatitis.pptx
acute pancreatitis.pptxacute pancreatitis.pptx
acute pancreatitis.pptx
 
Contrast Induce Nephropathy
Contrast Induce NephropathyContrast Induce Nephropathy
Contrast Induce Nephropathy
 

Más de Sidney Erwin Manahan

Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022Sidney Erwin Manahan
 
Treating Asymptomatic Hyperuricemia for Better CV Outcomes
Treating Asymptomatic Hyperuricemia for Better CV OutcomesTreating Asymptomatic Hyperuricemia for Better CV Outcomes
Treating Asymptomatic Hyperuricemia for Better CV OutcomesSidney Erwin Manahan
 
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)Managing CV risk in Inflammatory Arthritis (Focusing on Gout)
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)Sidney Erwin Manahan
 
B Vitamins and musculoskeletal disease
B Vitamins and musculoskeletal diseaseB Vitamins and musculoskeletal disease
B Vitamins and musculoskeletal diseaseSidney Erwin Manahan
 
Treatment Decisions in Osteoarthritis
Treatment Decisions in OsteoarthritisTreatment Decisions in Osteoarthritis
Treatment Decisions in OsteoarthritisSidney Erwin Manahan
 
Novel Targets in Osteoarthritis Manahan SIG 11 2014
Novel Targets in Osteoarthritis Manahan SIG 11 2014Novel Targets in Osteoarthritis Manahan SIG 11 2014
Novel Targets in Osteoarthritis Manahan SIG 11 2014Sidney Erwin Manahan
 
Updates in Fibromyalgia: Diagnosis and Management
Updates in Fibromyalgia: Diagnosis and ManagementUpdates in Fibromyalgia: Diagnosis and Management
Updates in Fibromyalgia: Diagnosis and ManagementSidney Erwin Manahan
 
Challenges in Managing Takayasu Arteritis
Challenges in Managing Takayasu ArteritisChallenges in Managing Takayasu Arteritis
Challenges in Managing Takayasu ArteritisSidney Erwin Manahan
 

Más de Sidney Erwin Manahan (14)

Joint and Back Pain Approach.pptx
Joint and Back Pain Approach.pptxJoint and Back Pain Approach.pptx
Joint and Back Pain Approach.pptx
 
Rational NSAID Use IM.pptx
Rational NSAID Use IM.pptxRational NSAID Use IM.pptx
Rational NSAID Use IM.pptx
 
Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022Lupus Nephritis Guideline Review 2022
Lupus Nephritis Guideline Review 2022
 
Treating Asymptomatic Hyperuricemia for Better CV Outcomes
Treating Asymptomatic Hyperuricemia for Better CV OutcomesTreating Asymptomatic Hyperuricemia for Better CV Outcomes
Treating Asymptomatic Hyperuricemia for Better CV Outcomes
 
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)Managing CV risk in Inflammatory Arthritis (Focusing on Gout)
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)
 
B Vitamins and musculoskeletal disease
B Vitamins and musculoskeletal diseaseB Vitamins and musculoskeletal disease
B Vitamins and musculoskeletal disease
 
Managing Lupus in Pregnancy
Managing Lupus in PregnancyManaging Lupus in Pregnancy
Managing Lupus in Pregnancy
 
Treatment Decisions in Osteoarthritis
Treatment Decisions in OsteoarthritisTreatment Decisions in Osteoarthritis
Treatment Decisions in Osteoarthritis
 
Novel Targets in Osteoarthritis Manahan SIG 11 2014
Novel Targets in Osteoarthritis Manahan SIG 11 2014Novel Targets in Osteoarthritis Manahan SIG 11 2014
Novel Targets in Osteoarthritis Manahan SIG 11 2014
 
2014 GSS Updates on Gout
2014 GSS Updates on Gout2014 GSS Updates on Gout
2014 GSS Updates on Gout
 
Updates in Fibromyalgia: Diagnosis and Management
Updates in Fibromyalgia: Diagnosis and ManagementUpdates in Fibromyalgia: Diagnosis and Management
Updates in Fibromyalgia: Diagnosis and Management
 
Challenges in Managing Takayasu Arteritis
Challenges in Managing Takayasu ArteritisChallenges in Managing Takayasu Arteritis
Challenges in Managing Takayasu Arteritis
 
Updates in OA 2011 Post Grad
Updates in OA 2011 Post GradUpdates in OA 2011 Post Grad
Updates in OA 2011 Post Grad
 
Hyperuricemia in CKD
Hyperuricemia in CKDHyperuricemia in CKD
Hyperuricemia in CKD
 

Último

MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 

Último (20)

MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 

Gout 2012: Updates to an Old Disease

  • 1. GOUT 2012: Updates to an Old Disease
  • 2. Assumptions “The ACR gout guidelines are designed to emphasize safety and quality of therapy and to reflect best practice.” • Correct Diagnosis • Consider Co-morbid conditions • Evaluate for Drug interactions 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.
  • 3. Levels of Evidence A Meta-analyses >1 Randomized Clinical Trial B Single Randomized Clinical Trial Non-Randomized Studies Standards of Care C Case Studies Expert Consensus
  • 4. Nomenclature (Acute) SEVERITY (Pain VAS) 1 2 3 4 5 6 7 8 9 10 DURATION (from onset of symptoms) 0 12 24 36 FREQUENCY (No of flares/ year) 1 2 3 4 5 6 7 8 9 10
  • 5. Nomenclature JOINT INVOLVEMENT • Few small joints • 1 or 2 large joints • Polyarthritis • 4 or more joints involving >1 region • 3 large joints
  • 6. 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
  • 7. 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.
  • 8. ACUTE GOUT a.k.a. GOUT FLARE Self limited attack of joint inflammation
  • 9. 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)
  • 10. Choosing an Anti-Inflammatory Start Pain VAS Yes <7/10 MONOTHERAPY (A) No CONSIDER Start • Patient preference COMBINATION • Prior response to meds THERAPY (C) • Associated co-morbids
  • 11. 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)
  • 12. 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
  • 13. 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)
  • 14. Combination Therapy in Acute Gout • Colchicine with NSAIDs • Colchicine with Steroids • IA Steroids with Colchicine/ NSAIDs/ Oral Steroids • Consider topical ice application (B)
  • 15. 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)
  • 16. Contraindications CONDITION NSAIDs Colchicine Steroids Chronic Kidney Disease St 3-5   Peptic Ulcer Disease   Heart Failure  Anti-coagulants/ platelets  Diabetes Mellitus  Infection  Liver Disease  
  • 17. Continuing Acute Gout Care INADEQUATE RESPONSE REVIEW the diagnosis Yes <20% in 24H CONSIDER or <50% after • Shift to other drug (C) 24H • Combine therapy (C) No • Anakinra 100 mg SC for 3 days (B) • Canakinumab 150 mg COMPLETE SC single dose (A) TREATMENT
  • 18. PROPHYLAXIS To be started in all patients in whom Urate Lowering Therapy is indicated
  • 19. 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)
  • 20. 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)
  • 21. URATE LOWERING THERAPY Pharmacologic and Non-Pharmacologic
  • 22. Diet and Lifestyle Changes AVOID LIMIT ENCOURAGE Organ meats (B) Seafood (B) Low fat or non-fat dairy Drinks with fructose(C) Sweetened fruit juices (C) products (B) Alcohol overuse (B) Sugar (C) Vegetables (C) Alcohol during an acute Salt (C) attack (C)
  • 23. 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
  • 24. Checklist COMORBIDS (C) • Obesity LABORATORIES • Alcohol intake • Urinalysis • Metabolic Syndrome and • Renal ultrasound components • CBC • Kidney disease • Urine uric acid • Lead intoxication determination (C) • Myeloprolif/ lymphoprolif – Gout < 25 y/o disorders – Nephrolithiases • Psoriasis
  • 25. Indications for ULT • Evidence of tophus/tophi (A) • Frequent attacks (>2/year) (A) • History of nephrolithiases (C) • Chronic Kidney Disease Stage 2-5 (C)
  • 26. Target Blood Uric Acid <6 mg/dl <5 mg/dl For most gout scenarios For more durable (if without visible tophi) improvement and patients (A) with visible tophi (B)
  • 27. 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)
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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)
  • 32. Consider referring when… • Unclear etiology of hyperuricemia • Refractory gout • Difficulty in achieving target BUA • Multiple or serious AE from ULT

Notas del editor

  1. Why did the ACR come up with recommendations – as other societies had published their guidelines much earlier (e.q. EULAR, British Society of Rheumatology, etc)? The goal was not to create new classification system or a paradigm shift in the way we manage gout. But rather to appraise current evidence on what is effective and safe to give to gout patients and to summarize these to reflect the best standards of care. The recommendations did not cover the diagnosis of patients with gout but instead focuses on how we should be managing gout. It assumes that a correct diagnosis of gout was made. That a thorough evaluation of co-morbid conditions was carried – particularly those which impact on how gout care would change. And a review of medications to evaluate for potential drug-drug interaction.
  2. Rather than evaluate the strength of the recommendation, the ACR merely provides us with an assessment of the quality of evidence available to support a recommendation. It does not follow that a recommendation having a higher level of evidence would be better than something having lower quality. Nor would a lower level of evidence mean that an intervention should not be considered.
  3. Severity is assessed by using the Pain VAS. &lt;4 mild, 5-6 moderate, &gt;7 severe.Duration is defined by the time from the onset of signs and symptoms of gout. &lt;12 hours – early, 12-36 hours – established, &gt;36 hours – lateFrequency is based on the number of flares occuring in a year. &lt;1 – infrequent, 2-6 frequent, &gt;7 very frequent
  4. Large joints – ankles, knees, hips, elbows, wrists and shouldersRegions - forefoot, midfoot, hindfoot, knee, hip, wrist, elbow, shoulder
  5. Simple tophi – lack of drainage, lack of aggressive mass or destructive effects, low risk of tophus infection, stable in size/ slow growth, lack of severe chronic tophaceous joint inflammationComplicated tophi – drainage, aggressive mass or destructive effects, high risk of infection, very rapid growth and with severe chronic tophaceous inflammation.
  6. Recommended doses: Naproxen 500 mg BID, Indomethacin 50 mg TID, Sulindac 200 mg BIDBased on an RCT (which Dr JLY was part of) the dosing of Celecoxib was 800 mg initially then another 400 mg on D1 then 400 mg BID from D2 – D8
  7. All life style changes – weight loss and exercise, healthy overall diet, smoking cessation, hydration- have Evidence Level C.
  8. Consider increased OFI and urine alkalinization when using uricosurics
  9. Start at low dose to reduce gout flares associated with ULT initiation and as risk reduction for AHS
  10. Did not recommend Allopurinol Maintenance Dosing based on Renal Function (C)
  11. Uricosurics - (probenecid, losartan, fenofibrate) – sulfinpyrazone (Available in the Phils) and benzbromarone were not recommended simply due to paucity of literature on their utility in such setting