Cumming School of MEDICINE

Division of Rheumatology

CALGARY AND AREA

Specialist LINKLinking Physicians

|September,2017-1

CONFIRMATION: ReferralReceived

TRIAGECATEGORY: EnhancedPrimaryCarePathway:GoutREFERRALSTATUS: ACCEPTEDconsideractionsinthemedicalhomeasoutlinedbelowDearColleague,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithadiagnosisofgout.ManypatientswithgoutcanbemanagedsuccessfullywithinthemedicalhomewithouttheneedforspecialistconsultationusingtheattachedEnhancedPrimaryCarePathway.Pleasefeelcomfortableinstartingthispatientonstandardtherapywhiletheywaittobeseen.Ifyoufeelthatconsultationisnolongerrequired,pleasecancelthereferral.Adefinitivediagnosisandlongtermtreatmentplanshouldbesoughtwhenevergoutissuspected.Somepatientsdorequirespecialistcare,particularlyiftheirpresentationisatypical,theyarenotrespondingtostandardtherapyortheyhavesignificantcomorbiditiessuchaschronicrenalfailure.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworksinpartnershipwiththeSectionofRheumatologyandAlbertaHealthServices.Theselocalguidelinesarebasedonbestavailableevidence,currentlocalresourcesandarepracticalintheprimarycaresetting.Thispackageincludes:

1. Focusedsummaryofgoutrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail

ThisreferralisACCEPTEDandanappointmenttimeispending.Thepatientwillbecontacteddirectlywithappointmentinformationonceavailable.Fornon-urgentrheumatologyadvicecallSpecialistLINKat403.910.2551ortoll-freeat1.844.962.5465available08:00-17:00weekdays.Thankyou,DivisionofRheumatology

PatientName: DateofReferral:

DateofBirth: ReferringMD:

CalgaryRHRN: Fax:

PHN/ULI: Today’sDate:

September,2017-2

EnhancedPrimaryCarePathway:Gout

1.FocusedsummaryofgoutrelevanttoprimarycareSignificance:Goutisachronic,progressive,inflammatorydiseaserequiringappropriatelong-termmanagement.Goutisincreasinginincidenceandprevalenceandisthemostcommoncauseofinflammatoryarthritisinmenover40yearsofage.Itisveryrareinpremenopausalwomen.Goutisacurablediseasethatisvastlyundertreatedworldwide,mainlyduetomisconceptionsregardingurateloweringtherapy,resultinginpermanentjointdamageanddisability.Pooradherencetotherapyiscommon,andpatientsrequireongoingeducationandmonitoring.Hyperuricemiaandgoutarestronglyassociatedwithhypertension,themetabolicsyndrome,renalimpairmentandcardiovasculardisease.ClinicalFeatures:Classicacutegouttypicallyaffectsonejointbutseveraljointscanalsobeinvolved.Themostcommonlyinvolvedareas(indecreasingfrequency)are:thefirstMTP(“podagra”),instep,ankle,heel,knee,wrist,fingersandelbow.Goutcanalsoaffectbursae,especiallyovertheelbows,kneesorAchillestendon.Theaffectedjointandsurroundingsofttissuesareexquisitelypainful,warm,redandswollen,andcanresemblecellulitis.Patientsmaynotbeabletotolerateevenabedsheettouchingtheaffectedjointandmaybeunabletowalk.Theattacksusuallylast3to10days,andpeelingoftheskinoverthejointmayoccurastheattackresolves.Withouturateloweringtherapy,theattacksmayincreaseinfrequency,involvemultiplejoints,persistlongeranddepositsofuricacidinthesofttissues(tophi)willoccur.Tophiarestronglyassociatedwithdestructiveanddeformingjointdisease.PotentialTriggersofGoutAttacks:

Diagnosis:Althoughthegoldstandardtestisidentificationofuricacidcrystalsinfreshsynovialfluidonpolarizedmicroscopy,thismaynotbefeasibleinsomepatients,orinaprimarycaresetting.Serumuricacidlevelscanbenormalduringanacutegoutattack,butwillbeelevatedatsomepointinalmostallgoutpatients.Althoughnotallhyperuricemicpatientshavegout,theriskofgoutishighwithpersistentserumuratelevels>580umol/L.X-raysareNOTusefulformakinganearlydiagnosisbeforepermanentdamageoccurs.DiagnosticdilemmasshouldbereferredtoRheumatology.Ifsynovialfluidanalysisisnotpossible,diagnosticalgorithmsmayhelptodeterminewhethertheprobabilityofgoutislow,intermediateorhigh.The“GoutDiagnosisCalculator”wasdevelopedforthispurpose(seeLinksbelowforfreeapp).Iftheprobabilityisintermediate,thepatientshouldbefollowedcloselyandsynovialfluidanalysisperformedwhenpossible.TheACR-EULARGoutClassificationCriteriaCalculator(seeLinksbelowforURL)isanotherhelpfuldiagnostictoolforgout.

Dietary Excessalcohol,purines(meat,seafood),fructose(soda,juice,energydrinks)Drugs/iatrogenic Diuretics,lowdoseASA,chemotherapy,radiationAcutemedicalillness Hemorrhage,infection,renalinsufficiency,dehydration,surgeryTrauma Injurytojoint(maybeminor)Endocrine Hypothyroidism,hyperparathyroidism

September,2017-3

2.Checklisttoguideyourin-clinicreviewofthispatientwithgoutsymptoms

o Isthehistoryconsistentwithtypicalgoutattacks?Considerusingdiagnostictool(seelinkbelow)

o Arethereanyredflagstosuggestinfection?

o Doesthepatienthaveahistoryofkidneystones,ortophionexamination?

o Arethereanypotentialgouttriggers,includinglifestylefactors?

o Reviewandtreatmodifiablecardiacriskfactors.

3.Linkstoadditionalresources

Forphysicians:

Diagnosticruleforgoutwithoutjointfluidanalysis: Download“GoutDiagnosisCalculator”freefromtheAppStoreorusetheonlinetoolat:https://www.mdcalc.com/acute-gout-diagnosis-rule

ClassificationCriteriaforGout(onlinetool)http://goutclassificationcalculator.auckland.ac.nz/

http://rheuminfo.com/diseases/gout(hasinformationforphysiciansandpatients)

www.goutinstitute.ca

https://www.niams.nih.gov/health_Info/Gout/default.asp

Forpatients:

www.rheuminfo.com/diseases/gout

www.gouteducation.org

http://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-healthy-eating-for-managing-gout.pdf

ThisAHSCalgaryZonepathwayhasbeendevelopedwithconsiderationofguidelines.Thefollowingisabest-practiceclinicalpathwayformanagementofGoutintheprimarycaremedicalhome.

4.SuspectedGoutPathway

September,2017-4

September,2017-5

1. GENERALPRINCIPLES• Allpatientswithgoutshouldbefullyinformedofthecausesofgout,managementprinciples&

lifestylemodifications(includingweightloss,regularexercise,alcoholuseanddiet)• Screenallpatientsforcomorbiditiesincludingrenalimpairmentandcardiovascularriskfactors• Treatacuteattacksassoonaspossible;earlytreatmentcanpreventafullblownattack• Goutgenerallycannotbemanagedwithdietalone,butcanbecuredwithacombinationofdiet

controlandurateloweringtherapy.• ~40%ofurateisfromdiet;60%isanormalwasteproduct(blockedbyallopurinolorfebuxostat)

DietaryAdviceforGout

Patientsshouldlimitconsumptionof -meats,especiallyorganmeat(liver,kidneyetc.)-seafood,especiallyshellfish,sardinesandanchovies-alcohol,especiallybeer

Moderateintakeofotherpurine-richfoodsshouldnotaggravategout

-purine-richvegetables(asparagus,cauliflower,spinach,mushrooms)-nuts-legumes(beansandpeas)

Intakeofthefollowingmayreducetheriskofgoutattacks

-coffee(usedecaffeinatedif>2cups/day)-vitaminC(500mg/day)-lowfatdairy(milk,yoghurt)-tartcherries(notinpillform)

2. TREATMENTOFACUTEGOUTATTACKSTREATMENT DOSAGE COMMENTSOralcolchicine -0.6mgpoBIDuntilattacksubsides

-0.3mgOD-BIDifGFR30–50mL/min-moreeffectiveifstartedwithinthefirst36hrofanattack

-contraindicatedifsevererenal(GFR<30mL/min)orhepaticinsufficiency-DONOTuseoldregimenswithfrequentdosesuntilpatienthasdiarrhea-usecautionifonimmunosuppressivedrugsduetopotentialdruginteractions

Corticosteroids -prednisone30mgPOODx5daysOR-Kenalog®(triamcinoloneacetonide)1mg/kgor80mgIMx1intoglutealmuscle(usea22Gx1.5inchneedle)

-canbeusedsafelyinchronickidneydisease-saferthanNSAIDsorcolchicineintheelderly

NSAIDs -indomethacin25-50mgTID,OR-naproxen250-500mgBID-thentaperoffaftersymptomssubside

-oftencontraindicatedduetocomorbidities-otherNSAIDs(fulldose)maybeaseffectiveasindomethacin-considergastroprotection

Intraarticularsteroids

-40-80mgoftriamcinolone(Kenalog®)forlargerjoints-10-20mgofmethylprednisolone(DepoMedrol®)forsmalljointsorbursae

-usefulintreatmentof1or2involvedjoints-sometimesmoreeffectivethanoralcorticosteroids-aspiratingexcesssynovialfluidpriortoinjectionofsteroidhastherapeuticbenefit-synovialfluidaspirateshouldbesenttolabforcellcount,culture,andcrystals

September,2017-6

3. TREATMENTOFCHRONICGOUTA.Indicationsforurateloweringtherapy(Note:TreatmentisusuallyLIFELONG!)

• Morethan2or3acuteattacksofgoutwithin1to2years(orunremittinggoutyinflammation)• Radiographicevidenceofjointdamageduetogout• Presenceoftophi• Establishedgoutwithchronickidneydiseasestage2orworse(GFR<90mL/min)• Renalstones(urate)

B.GoutFlareProphylaxis(Mandatorywhileinitiatingurateloweringtherapy)• Continuecolchicineprophylaxisfor:

• 3monthsafterachievingtheserumuricacidgoalinpatientswithouttophi,OR• 6monthsafterachievingtheserumuricacidgoalinpatientswith1ormoretophi,OR• continueprophylaxisforlongerifacutegoutflarespersist

• ItiscommonpracticetotreatwithBOTHcorticosteroids(singleIMdoseorshortcoursePO)ANDcolchicinewheninitiatingurateloweringtherapy.

Colchicine 0.6mgpoODorBID,or

0.3mgpoODorBIDifelderlyorGFR30to50mL/minDonotuseifGFR<30mL/min

Corticosteroids -Kenalog®(triamcinoloneacetonide)80mgIMdeepintoglutealmuscle,OR-Prednisone20mgPOODinpatientswithcontraindicationstoNSAIDsandcolchicine,taperby5mgperweek

NSAID e.g.naproxen250mgto500mgpoBIDwithaprotonpumpinhibitorPotentialforsignificantsideeffectsifcomorbidities(renaldisease,elderly)AvoidprophylaxiswithcombinationofNSAIDsandoralprednisone

C.InitiationofUrateLoweringTherapy(Target:serumurate<360umol/L;<300umol/Liftophi)

• Allopurinol300mgPOODcanbestartedinpatientsonprophylaxiswithsteroidsandcolchicine.• Alternatively,thedosecanbeslowlytitrateduptominimizetheriskofgoutattacksasfollows:

-Allopurinol100mgPOODx2to4weeksà-Allopurinol200mgPOODx2to4weeksà-Allopurinol300mgPOODthereafter(300mgissufficientformost;cost~33¢pertablet)à-Allopurinoldosemaybeincreasedto400mgifserumuratelevelremainsabovetargetà-RefertoRheumatologyifnotresponding.

• CBC,CRP,Cr,ALT,albumin,uricacidmonthlyuntiluratestable,thenevery6to12months• Febuxostat80mgPOODoreveryotherdaycanbeusedinsteadofallopurinolinpatientswithstage4or5CKD(GFR<30mL/min),orothercontraindicationstoallopurinol.BlueCrossrequiresaspecialauthorizationform(cost~$1pertablet),butmostprivateinsurersdonot.

September,2017-7

4. CONTRAINDICATIONS/REASONSTOSTOPURATELOWERINGTHERAPYThevastmajoritywilltolerateallopurinolwell.Themostcommonconcernisan↑ingoutattacksduringinitiationoftreatment,suchthatgoutprophylaxisismandatory.DONOTstopallopurinolforagoutattack.Allopurinolandfebuxostatshouldnotbeusedinpatientsonazathioprine(Imuran®)duetotheriskofbonemarrowfailure(refertorheumatology).Patientswithallopurinolhypersensitivity(rash,fever,↓platelets,↑liverenzymes)shouldstopimmediatelyandnevertakethisdrugagain.

HLA-B*58:01TESTINGFORETHNICGROUPSATRISKFORHYPERSENSITIVITYREACTIONSChinese,ThaiandKoreanpatientsareatriskforlife-threateningallopurinolhypersensitivityreactions.HLA-B*5801screeningshouldbeconsideredinthesepatientsbeforestartingallopurinol,andifpositiveallopurinolshouldnotbeused.ThisgenetictestcanbeorderedthroughCLS.High-riskindividualsshouldbetreatedwithfebuxostatinstead.

TheGoutEnhancedPrimaryCarePathwaywasdevelopedbythefollowingindividualsincollaborationwiththeCalgaryZonePrimaryCareNetworks,theDivisionofRheumatology,andAlbertaHealthServices:

SusanBarrMD,MSc,FRCPCAssociateProfessorofMedicineSectionofRheumatology

PaulMacMullanMD,MBBChBAO,MRCPIClinicalAssociateProfessorSectionofRheumatology

MonicaSargiousMD,CCFP,FCFPSectionChiefCommunityPrimaryCareDepartmentofFamilyMedicineAlbertaHealthServices–CalgaryZone

OliverDavidMD,CCFPMedicalDirector,MosaicPrimaryCareNetwork