11 responses to “Part 2: Treating Gout – Practice Tips and Clinical Pearls”

  1. This is a helpful article. Personally I like to inject acute joints with steroid when possible. I will certainly consider combination NSAID/colchicine in resistant episodes of gout.

  2. I usually treat with Indocid but now will add Cochicine

  3. Good summary of steps to treat gout.
    I also encourage drinking of lots of water (lowers uric acid) and 1 or 2 Vitamin C 500 mg (folklore suggests ‘black cherry juice’) to also lower uric acid.
    In addition I suggest avoiding soft drinks with fructose sweetener and gradual weight loss.
    Patients appreciate the ‘non-medical’ interventions in addition to the very necessary treatment of acute inflammation.
    I was unaware of testing for HLA-B*5801 status. Thanks for that tip!

  4. Is there any role for splinting in acute gout?

  5. some good tips, thanks – #9 especially is a good reminder

    a few important points:

    1) diet and lifestyle have been omitted from this article; there is very little evidence around this – only observational studies so far showing an association (http://www.cochrane.org/CD010039/MUSKEL_lifestyle-interventions-for-chronic-gout). Since that review, one paper https://www.ncbi.nlm.nih.gov/pubmed/26500085 suggests presentation with gout is correlated with a 9-fold increase in alcoholism. It is yet to be determined whether asking about alcohol intake (or any intervention) could decrease the number of gout flares an individual has.

    2) there is some evidence to suggest that ongoing/high dose (4.8 mg total over 6 hours) treatment with colchine is not better than low dose (1.8mg over 1 hour) but may cause more harm for acute flares:

    http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013795/ (Cochrane review)

    http://www.ncbi.nlm.nih.gov/pubmed/query.fcgi?cmd=Retrieve&list_uids=20131255&dopt=Abstract (LOE = 1b, featured as an infoPOEM)

    3) choice of NSAID
    for some reason, indomethacin (indocid) keeps getting used for gout. ANY NSAID will do and some have fewer adverse events and/or lower costs. Naproxen is considered the safest with respect to cardiovascular risk profile though other considerations may apply

    4) monthly uric acid levels may be excessive and are unlikely to change management; UpToDate suggests “Serum urate levels should be monitored to assure maintenance of concentrations in the goal range and to permit antihyperuricemic drug dose adjustment as needed. One approach is to determine serum urate concentration within two to four weeks of a dose adjustment, with confirmation three months later. Once goal values are confirmed, measurement every six months for the next year and then annually is usually adequate, unless drugs or lifestyle factors potentially altering urate levels have been introduced in the interim.”

    5) RheumInfo is unfortunately has pharma-funding as does Dr S and so the advice offered must be viewed with these considerations in mind.

  6. Hello,

    Thank you for this helpful article.

    Is HLA-B*5801 status testing covered by MSP?
    How does a positive test for HLA-B*5801 change management? Would you suggest avoiding allopurinol completely or start at a lower dose and titrate more slowly?

  7. How long we should keep the patient on ALLOPURINOL?

  8. Thanks everyone for your comments and feedback.

    Dietary changes should definitely be discussed with patients – alcohol, red meat, in addition to high fructose corn syrup containing foods/beverages. Hydration is important as mentioned above. Furthermore, cherries have been shown to be uricosuric, and a handful cherries once daily sound reasonable to us. However, these alone may not be sufficient to prevent further occurrences of gout in your patient.

    There is currently no role for splinting/immobilization in acute management of gout. I called BC Bio Laboratories. It appears the HLA-B^5801 testing is covered by MSP (the blood gets sent to Vancouver General Hospital lab for testing). I would avoid starting Allopurinol in patients who test positive, given the high likelihood of adverse reactions.

    Allopurinol is considered a “life long” treatment. Of course, if a patient has not had a flare in years, and is insistent to be taken off the medication, this can be attempted. But they should be warned they will likely have another flare.

  9. I had always considered Indocid as the Go-To NSAID for gout, but will now use the others more readily. I don’t think Indocid is covered by Pharmacare without Special Authority – and I rarely request it – so there can be added cost to patient. I will more eagerly add Colchicine to acute therapy.

    Thank you for excellent summary.

  10. Very useful article especially about treatment of acute gout. The combination of NSAIDS and Colchicine sounds great and also the use of Allopurinol in ckd patients and the tips to prevent acute attacks.

  11. My 47-yr old male patient has been on Allopurinol for circa 6 years.

    2.5 years ago he suffered a concussion via a hit in the back of the head. He has since complained of brain fog and fatigue that has not improved. The brain fog did not intensify until 3-4 months post concussion.

    The patient believes the allopurinol is driving the brain fog and making the concussion recovery slower as the fog seems to lessen when he takes Allopurinol less frequently.

    Has anyone else dealt with this symptom presentation? Or seen brain fog as a side effect? Some patients in inline forums have also complained of intense brain fog and fatigue.

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