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

Management

Problems

• Chronic tophaceous gout in flare

• Ulcers on sole of left foot

• Leukocytosis with neutrophilia

• Anemia and possible GI bleeding

• Hypertension

Therapeutic goals

• Treat acute gouty arthritis

• Wound management for ulcers on sole of left foot

• Treat infection

• Treat anemia and GI bleeding

• Manage hypertension

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


In the absence of contraindications

Li-Yu J, et al. (2008) Philippine Clinical Practice Guidelines for Uncomplicated Gout. Philippine Rheumatology Association.

4 tablets in divided doses per day

initially at 30 mg and rapidly tapered over 6 days can be given as alternative

Allopurinol started at 100 mg/day 2 weeks after the pain and swelling has subsided. Dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve SUA <6 mg/dL. The maximum dose of allopurinol is 300 mg/day. SUA and serum creatinine should be periodically monitored.



Absence of response after a week should prompt re-evaluation of the diagnosis and referral to a rheumatologist


• In the absence of contraindications, i.e.. renal impairment or gastrointestinal ulcers, the use of colchicines, traditional non-steroidal anti-inflammatory drugs (NSAIDs), OR selective cyclo-oxygenase 2 (COX-2) inhibitors is recommended for the treatment of acute gouty arthritis.

• The expert panel recommends that colchicines should not exceed 4 tablets in divided doses per day.

• Prednisone, initially at 30 mg and rapidly tapered over 6 days can be given as alternative if colchicines, traditional NSAIDs or COX-2 inhibitors are contraindicated or not tolerated by the patient

• Absence of response after a week should prompt re-evaluation of the diagnosis and referral to a rheumatologist

• Ice compress is recommended in combination with pharmacologic agents for relief of joint pain and swelling of acute gouty arthritis


• Serum uric acid (SUA) level should be reduced to and maintained at <6 mg/dL (0.36 mmol/L)

• Continuous long term therapy with allopurinol is advised to achieve a target SUA level of <6 mg/dL

• Allopurinol should be started at 100 mg/day 2 weeks after the pain and swelling of gouty arthritis has subsided. The dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve SUA <6 mg/dL. The maximum dose of allopurinol is 300 mg/day. SUA and serum creatinine should be periodically monitored.

• A referral to an internist or rheumatologist is recommended if SUA persistently remains > 6 mg/dL despite maximum dose.

• Colchicine should be used at 0.5 mg/tab OD BID to prevent gout flares when initiating urate-lowering therapy with allopurinol. This should be maintained for 3-6 months from the last occurrence of gout flare and after the optimal SUA target is achieved. In the event that adverse events like diarrhea occur, a lower dose of colchicines should be used. NSAIDs should not be used for prevention of gout flares.

• Dietary modification (to promote weight loss) and avoidance of alcohol should be prescribed.

• Low impact exercises (walking, biking, swimming, ballroom dancing) may also be advised.


Management of acute gout(1) Affected joints should be rested and analgesic, anti-inflammatorydrug therapy commenced immediately, andcontinued for 1–2 weeks.(2) Fast-acting oral NSAIDs at maximum doses are the drugs ofchoice when there are no contraindication.(3) In patients with increased risk of peptic ulcers, bleeds orperforations, co-prescription of gastro-protective agentsshould follow standard guidelines for the use of NSAIDsand Coxibs.(4) Colchicine can be an effective alternative but is slower towork than NSAIDs. In order to diminish the risks ofadverse effects (especially diarrhea) it should be used indoses of 500g bd–qds.


(5) Allopurinol should not be commenced during an acuteattack but in patients already established on allopurinol,it should be continued and the acute attack should be treatedconventionally.(6) Opiate analgesics can be used as adjuncts.(7) Intra-articular corticosteroids are highly effective in acutegouty monoarthritis and i.a., oral, i.m or i.vcorticosteroids can be effective in patients unable to tolerateNSAIDs, and in patients refractory to other treatments.(8) If diuretic drugs are being used to treat hypertension, analternative antihypertensive agent should be considered, butin patients with heart failure, diuretic therapy should not bediscontinued .


Wound Management

• Debridement may he accomplished by sharp, mechanical, enzymatic, and/or autolytic measures.

• Wounds should be cleaned initially and each dressing changed by a nontraumatic technique.

• Use normal saline• Selection of a dressing should ensure that the

ulcer tissue remains moist and the surrounding skin dry.

James, WD, et al. (2006). Andrews’ Diseases of the skin: Clinical Dermatology, 10th ed.

Leukocytosis with neutrophilia

• Broad spectrum antibiotics which one??

Anemia and GI bleeding

• Proton pump inhibitor (Omeprazole)

• Blood transfusion

Hypertension …which one??

• Diuretics• Anti-adrenergics

– Adrenoceptor Blockers– Alpha Adrenoceptor Blockers– Beta Adrenoceptor Blockers– Adrennergic Neuron Blockers– Centrally Acting Anti-hypertensives

• Direct Vasodilators• Calcium Channel Blockers• Angiotensin Converting Enzyme (ACE) Inhibitors• Angiotensin 2 Receptor Blockers (ARB)

Given in ward

• Omeprazole 40 mg tab OD• Amlodipine 10 mg tab OD• Clindamycin 300 mg cap q 6• Ciprofloxacin 250 mg tab BID• Given Colchicine as follows to treat acute

gout: 2 tabs now then 1 tablet after 6 hours

• Cold compress x 10-15 mins TID on inflamed joints

Thank you!!!

Febuxostat

• nonpurine selective inhibitor of xanthine oxidase.

• acts by binding into a channel in the molybdenum center of the enzyme, leading to a very stable and long-lived enzyme-inhibitor interaction with both the oxidized and reduced forms of the enzyme and, as a consequence, a strong inhibition of substrate binding

Gaffo, AL and Saag KG. (2009). Febuxostat: the evidence for its use in the treatment of hyperuricemia and gout. Core Evid 4:25-36

ANTIGOUT• For acute gout• COLCHICINE Oral: 500 mcg tablet• NSAIDs

• For chronic gout• ALLOPURINOL Oral: 100 mg and 300 mg

tablet

PNDF Vol. I, 7th ed. (2007)

• 2.4 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

• 2.4.1 Non-selective COX inhibitors• IBUPROFEN • NAPROXEN • diclofenac • indometacin • ketoprofen • mefenamic acid

• 2.4.2 Selective COX 2 inhibitor• CELECOXIB

PNDF Vol. I, 7th ed. (2007)

Documents

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