Gout – ACR 2012 Guideline Part 2

Summary:

  1. Acute gouty Tx should be initiated within 24hr of onset
  2. Established urate-lowering Tx should be continued during an acute attack
  3. 1st line: NSAIDS, corticosteroids, or coral colchicine (combination for severe or refractory attacks)
  4. Anti-inflammatory prophylaxis for all gout pt when urate lowering Tx is initiaed and continued if any clinical evidence of gout activity and/or serum urate target hasn’t achieved.
    • 1st line gout attack prophylaxis Tx
      • Colchicine po – , with adjustment in CKD & drug interaction unless there is a lack of tolerance or c/i
      • Low-dose NSAID Tx unless there is a lack of tolerance or c/i

Severity of Acute Gouty arthritic attack – self-reported pain (0-10 scale)

  • Mild <=4, Moderate 5-6, Severe >=7

Duration of the gouty arthritis attack since onset

  • Early <12 hr, Well-established 12-36hr, late >36hr

Extent of acute gouty arthritis attack

  1. One or a few small joints
  2. 1 or 2 large joints: ankle, knee, wrist, elbow, hip, shoulder
  3. Polyarticular:
    • >=3 separate large joints
    • >= 4 joints, involving more than 1 region: forefoot (MTP, toes), midfoot (tarsal jt), ankle/hindfoot, knee, hip, fingers, wrist, elbow, shoulder, other

Management of an Acute Gout Attack: Assess Severity

  • Initiate med Tx within 24hr of onset & continue ULT (don’t interrupt)

A) Mild-Moderate pain affect 1 -2 large joints or a few small joints → Monotherapy

  1. NSAIDs > COX-2 – continue full dose until gouty attack has completely resolved
  2. Systemic Corticosteroids: (4 options)
    • Prednisone 0.5mg/kg/d for 5-10days then stop
    • Prednisone 0.5mg/kg/d for 2-5 days then taper for 7-10 days then stop
    • If 1-2 large joints: consider intra-articular corticosteroids
    • Triamcinolone acetonide 60mg IM then oral prednisone as above
  3. Colchicine (within 36hr) – 1.2mg then 0.6mg 1hr later + prophylaxis dosing 12hr later & continue until the attack resolves
    • Use NSAIDs or steroids if colchicine in the last 14 days
  • Inadequate Response (<20% improvement <= 24hr or <50% >=24hr)
    • switch to alt monotherapy or combination therapy
  • Successful Outcome
    • Pt education: Lifestyle, prompt self-tx of subsequent acute gout attacks & consider ULT

B) Severe pain, polyarticular attack or affecting multiple large joints → Combination therapy

  1. Colchicine + NSAIDs
  2. Oral corticosteroids + colchicine
  3. Intra-articular steroids + all other modalities
  4. (no oral corticosteroids + NSAIDs – synergistic GI toxicity)

Gout attack prophylaxis – With or just prior to initiating ULT

  1. 1st line:
    • Low dose colchicine: 0.5mg od – bid
    • Low dose NSAIDs with PPi: Naproxen 250mg bid
  2. 2nd line: If both NSAIDs and colchicine not tolerated, contra-indicated, or ineffective
    • Low dose Prednisone or Prednisolone (<=10mg/d)
  3. Duration:
    • + gout activity → Continue pharmacologic prophylaxis
    • no s/sx (3 options) → at least 6 months of prophylaxis OR
      • 3 months after achieving target serum urate (no tophi)
      • 6 months after achieving target serum urate (+ tophi)

NPO Pt

  1. Initial ACTH 25-40IU sc
  2. Intra-articular corticosteroids – dose varies by jt size
  3. Methylprednisolone 0.5-2mg/kg IV/IM
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Posted in 55 Joint Disorder, 99 Priority Topics, FM 99 priority topics, Rheum

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