THE GOUT

P R E S E N T E D B Y:

D A N T RA N

A M B U L AT O RY C A S E P R E S E N TAT I O N

OBJECTIVES
By the end of this presentation, you should be able
to:

Sort the following 4 preferred treatments, in order

of preference, for acute gout exacerbation: nonpharmacologic, NSAIDS, colchicine, and steroids
Identify alternative drug treatment options for
chronic gout in patients with severe renal
insufficiency or who are refractory to conventional
treatment.

SETTING
MTM and Medication Review Consult
New Patient to Franciscan Clinic
Cold Visit:
Reported chronic renal failure by referring physician.
No Prior Drug History, and no med list
No access to patient lab results

OVERVIEW OF CASE
MM is a 90 yr old caucasian female with recent
hospital discharge following a fall incident.
Clinical S/Sx:
Remarkably able-bodied,
appears obese, reports
feeling healthy, complains
about pain and
tenderness in great toe

SH:
Lives with husband in nonsmoking home.
Frequently gardens in backyard.
Denies alcohol use.

PMH:

History of renal insufficiency

Colon cancer (remission)
Anemia
Hip arthritis
Gout
Type 2 diabetes
Atrial fibrillation

Chronic Conditions:

Gout
Edema
Diabetes
Hyperlipidemia
Glaucoma
hypothyroidism

MEDICATION THERAPY
Indication

Drug

Gout

Allopurinol

Hypertension

Dose

Route

Duration/Frequency

300 mg

1 tablet

Po

Daily

Furosemide

20 mg

2 tablets

Po

Daily

Hyperlipidemi
a
Thyroid

Simvastatin

40 mg

1 tablet

Po

At bedtime

125 mcg

1 tablet

Po

Daily

Diabetes

Glipizide XL

2.5 mg

1 tablet

Po

Daily

Metformin

500 mg

1 tablet

Po

Twice a day

Glaucoma

PE
Prophylaxis
Pain

Levothyroxine

Strength

Timolol Maleate

0.5%

1 drop

In both eyes Twice daily

Travoprost
Warfarin Sodium

0.004%

1 drop

In both eyes At bedtime

3 mg

1 tablet

Po

Daily on Su/Tu/Th/Sa

Warfarin Sodium

2 mg

1 tablet

Po

Daily on Mon/Wed/Fri

25 mg

1 tablet

Po

Every 6 hours as needed

(average 1 tab/day)

1 capsule

Po

Every 4-6 hrs. as needed

(average 1-2
tabs/week)

Tramadol
Acetaminophen

500 mg

No reported herbals or other OTC products.

DRUG THERAPY EVALUATION

Concerns:
1. Metformin appears to not be on her med drug list or
hospitalization discharge paperwork list but was brought in
her brown bag.
2. Allopurinol and Metformin both require assessment in cases of
renal insufficiency.
3. Address the root cause behind pain in the patients great toe
and to relieve her discomfort.

DRUG THERAPY EVALUATION

Subjective/Objecti
ve

Evaluation

Presence of
inflammation in the
great toe indicative
of podagra

Podagra is a common acute

exacerbation of gout.

MM is taking
allopurinol 300 mg
for her gout

Allopurinol may build up and

increase risk due to her renal
Gout Evaluation:
function.

Dosing for pain meds

are appropriate. MM
reports mild usage of
these drugs.

It appears that pain is

adequately controlled with
current tramadol and
acetaminophen therapy.

GOUT: ETIOLOGY 1
Acute arthritis associated with monosodium urate
crystals in synovial fluid
Uric acid is a byproduct of xanthine oxidase in purine
metabolism

Elevated serum urate concentration: hyperuricemia

Uric acid vs. Monosodium Urate

Aggregates of crystals around joints can form tophi,

which is painful and can cause deformity
Associated with:
Renal failure and renal tissue disease: underexcretion of uric
acid
Uric Acid nephrolithiasis
1. Pittman JR, Bross MH. Diagnosis and Management of Gout. Am Fam Physician 1999
Apr 1; 59(7):1799-1806

DIAGNOSIS OF GOUT
Dx: 1977 ARA Criteria (any 6 of the following)

Etiology-related

1. Hyperuricemia
2. Monosodium urate microcrystals in joint
fluid during attack

MM reports having these

signs/symptoms

1.
2.
3.
4.

Unknown

1.
2.
3.
4.

Redness observed over joints,

Max inflammation developed in 1 day
Monoarthritis attack,
Unilateral first metatarsophalangeal joint
attack (great toe)
5. >1 attack of acute arthritis
Unilateral tarsal joint attack (ankle)
Tophus
Swelling within a joint on x-ray
Joint fluid culture negative during attack.

Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Y T-F. Preliminary criteria for the
classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895-900.

2012 ACR GUIDELINES

1.
2.

Khanna D, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharmacologic and pharmacologic
therapeutic approaches to hyperuricemia. Arthritis care & research 64.10 (2012): 1431-1446.
Khanna D, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute
gouty arthritis. Arthritis care & research 64.10 (2012): 1447-1461.

ACUTE GOUT 1
Goal: Stop the acute gout attack!
1st Line: Non-Pharmacologic

Reduce dietary intake of meals high in purines

Increase fluid intake, reduce salt intake
Apply ice to arthritic joints
Consider weight loss

2nd Line: NSAID

Indomethacin SR 75 mg BID until attack subsides. Alternatives:
naproxen and sulindac. Not appropriate for MM due to renal failure

3rd Line: Colchicine (PO)

Anti-mitotic drug, can cause GI effects (nausea, diarrhea)

4th Line: Steroids

1. Pittman JR, Bross MH. Diagnosis and Management of Gout. Am Fam Physician
1999 Apr 1; 59(7):1799-1806

CHRONIC GOUT
2 or more attacks per year = Chronic Gout
Therapy
Uricosuric Drug vs. Xanthine
.AllopurinolOxidase Inhibitor
Probenecid

Renal Dosing Consideration

Probenecid: contraindicated in patients with renal
insufficiency
Allopurinol 3 :
CrCl 20 ml/min : 100 mg po daily
CrCl 10 ml/min : 100 mg po every 2 days
CrCl 0 ml/min : 100 mg po every 3 days

Correct underlying causes (secondary)

3. Dalneth N, Stamp L. Allopurinol dosing in renal impairment: walking the tightrope
between adequate urate lowering and adverse events. Semin Dial 2007; 20:391-5.

ALTERNATIVE TREATMENT?
Uloric (febuxostat) 4
Xanthine Oxidase inhibitor
Recommended starting dose: Uloric 40 mg once daily

Eliminated by both hepatic and renal pathways

Use with caution in patients with severe renal

impairment
Following multiple doses 80 mg doses in patients with
severe renal impairment (CrCl 10-29 ml/min), the Cmax
of febuxostat did not change compared to patients with
normal renal function.
4. Uloric [package insert]. Deerfield, IL: Takeda Pharmaceuticals America, Inc;
2012.

ALTERNATIVE TREATMENT?
Krystexxa (pegloticase) 5
PEGylated enzyme specific for uric acid
Administered as IV push or bolus. Requires discontinuation of oral
urate-lowering agents before starting therapy.
No dose adjustment for renal or hepatic impairment

Indicated for adult patients refractory to conventional

therapy
Rapidly resolves gouty deposits and dramatically lowers uric acid
levels.
Severe infusion reactions (41%), gout flares, possibly worsen CHF.

Price: Allopurinol $100/yr , Uloric $2000/yr

Krystexxa $20,000/year
Krystexxa [package insert]. East Brunswick, NJ: Savient Pharmaceuticals, Inc.;
2010.

MMS CARE PLAN

Recommend non-pharmacological therapy
(1st line)
Acute gouty arthritis appears to be mild and pain is wellcontrolled with current non-opiate therapy.
Patient education to ice joint and reduce purine intake.

Get labs; reassess renal function.

Possibly consider changing therapy to Uloric (febuxostat)
40mg orally once daily if renal function worsens.

CARE PLAN
Monitor: Inflammation, worsening of symptoms
of hyperuricemia including joint pain or podagra,
renal function.
Efficacy: reduction/resolution of acute gout symptoms.
Toxicity: monitor for worsening symptoms, hyperuricemia,
reduction in renal function (SCr, CrCl

SUMMARY OF KEY POINTS

Gout is a heterogeneous group of diseases
associated with monosodium urate crystals in
synovial fluid and arthritic joint attack.
Acute gout exacerbation is primarily handled with
non-pharmacological treatment, then NSAIDS,
colchicine, and steroids.
Renal Insufficiency is a key concern related to most
common chronic gout treatments: Uricosuric drugs
and Xanthine Oxidase inhibitors (except Uloric).

QUIZ TIME!
MMs doctor asks you for an alternative drug
treatment option instead of allopurinol for MMs
chronic gout due to her severe renal insufficiency.
What other drug can you suggest?

1.
2.
3.
4.

Probenecid
Uloric
Zyloprim
There are no alternatives.

THE ANSWER IS A B C D. JUST NOT IN

THAT ORDER.
Sort the following 4 preferred treatments, in order
of preference, for acute gout exacerbation:

A. Colchicine
B. Non-pharmacologic
C. NSAIDS
D. Steroids
Order: ____ , _____ , _____ , _____

REFERENCES
1.

Pittman JR, Bross MH. Diagnosis and Management of Gout. Am Fam Physician 1999
Apr 1; 59(7):1799-1806

2.

Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Y T-F. Preliminary criteria for
the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895900.

3.

Dalneth N, Stamp L. Allopurinol dosing in renal impairment: walking the tightrope

between adequate urate lowering and adverse events. Semin Dial 2007; 20:391-5.

4.

Uloric [package insert]. Deerfield, IL: Takeda Pharmaceuticals America, Inc; 2012.

5.

Khanna D, et al. 2012 American College of Rheumatology guidelines for management

of gout. Part 1: Systematic nonpharmacologic and pharmacologic therapeutic
approaches to hyperuricemia. Arthritis care & research 64.10 (2012): 1431-1446.

6.

Khanna D, et al. 2012 American College of Rheumatology guidelines for management

of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis.
Arthritis care & research 64.10 (2012): 1447-1461.

7.

Krystexxa [package insert]. East Brunswick, NJ: Savient Pharmaceuticals, Inc.; 2010.