Pharmacology
Musculoskeletal
A 34 year old overweight man, who has a history of gout, presents to ED with an acutely exquisitely tender big toe. His big toe is red, hot and swollen, but he is apyrexial and otherwise systemically well. Acute gout is diagnosed. What is the most appropriate first line treatment for this patient:
Answer:
NSAIDs (such as diclofenac, indometacin or naproxen) are usually the first line treatment for acute gout. Colchicine is an alternative in patients in whom NSAIDs are contraindicated, not tolerated or ineffective. Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate or who are resistant to NSAIDs and colchicine. Intra-articular injection of a corticosteroid can be used occasionally in acute monoarticular gout. Allopurinol is not a treatment for acute gout (but should be continued during an acute attack if the patient is already established on long term therapy).Management of Gout
Pharmacology / Musculoskeletal
Last Updated: 27th March 2019
Gout is a disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) and the deposition of urate crystals in joints and other tissues, such as soft connective tissues or the urinary tract.
NSAIDs
Acute attacks of gout are usually treated with an NSAID such as diclofenac, indometacin, or naproxen. Treatment should be started as soon as possible and continued until 48 hours after the attack has resolved. A PPI should be co-prescribed for gastric protection in people at high risk of gastrointestinal adverse events.
Colchicine
Colchicine is an alternative in patients in whom NSAIDs are contraindicated, not tolerated or ineffective. Although its use is limited by toxicity at higher doses, it is useful in patients with heart failure or those taking anticoagulants.
The dose is 500 micrograms 2 - 4 times a day until the symptoms are relieved or diarrhoea or vomiting occurs (max 6 mg per course and do not repeat treatment within 3 days).
Colchicine should be avoided in people with blood dyscrasias and bone marrow disease.
Common side effects of colchicine include:
- abdominal pain
- nausea and vomiting
- diarrhoea
Side effects are dose dependent and may be severe enough to limit treatment.
Corticosteroids
Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate or who are resistant to NSAIDs and colchicine. Intra-articular injection of a corticosteroid can be used occasionally in acute monoarticular gout.
Allopurinol
Allopurinol is not effective in treating an acute attack and may prolong it indefinitely if started during the acute episode, but should be continued during an acute attack if the patient is already established on long term therapy.
Long term treatment (prevention) of gout may be indicated in patients with frequent recurrence of acute attacks of gout, the presence of tophi, or signs of chronic gouty arthritis. Allopurinol reduces uric acid formation from purines and may be used to prevent further attacks of gout by correcting hyperuricaemia. The initiation of treatment may precipitate an acute attack, and should be covered with an NSAID or colchicine, continued for at least one month after the hyperuricaemia has been corrected.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
