DRUG TREATMENT OF

GOUT
Alberto Beltrn Rojas Cruz

GOUT
Also

called crystal-induced arthritis, is an

arthritic condition that occurs when uric
acid crystals accumulate in the joints.
Gout usually affects the large joint of the
big toe, but can also affect other joints,
such as the knee, ankle, foot, hand, wrist
and elbow.
In rare cases, it may later affect the
shoulders, hips or spine.
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 Uric

acid is a substance that normally forms

when the body breaks down waste products
(called purines).
Uric acid is usually dissolved in the blood
and passes through the kidneys into the
urine.
For people with gout, the uric acid level in
the blood is so high that uric acid crystals
form and deposit in joints and other tissues.
Uric acid level in patients with gout should
be kept below 6 mg/dL
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 After

several years, the crystals can build

up in the joints and surrounding tissues,
forming large deposits, called tophi.

Although the exact cause is

unknown, gout may be caused
by

Genetic defect in metabolism, which causes

overproduction and retention of uric acid
kidney impairment that prevents normal
elimination of uric acid
thiazide diuretic medications (water pills) used
to treat high blood pressure and heart failure
environmental factors, such as obesity, alcohol
abuse and a purine-rich diet.
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Symptoms of Gout
Gout

generally occurs in four stages:

(1)Asymptomatic stage - urate levels rise

in the blood, but produces no symptoms
(2) Acute stage - 5 to 10 days sudden
attack of joint pain, swollen, tender, dusty
red joint
(3) Intercritical stage - Symptom free
interval
(4) Chronic stage - persisten pain, stiffness
and limited motion of joint, accompanied
with sores and white pus.
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Diagnosis of Gout
The diagnosis of gout is based on
symptoms, blood tests showing high
levels of uric acid, and the finding of
urate crystals in joint fluid.
In chronic gout, x-rays show damage
to the cartilage and bones.

MANAGEMENT
Proper

diet
Avoid or restrict foods high in purine.
These foods include: liver, shellfish
(mussels and oysters), fish , scallops,
peas, beans and an excessive amount of
red meat.
Drink 10 to 12 eight-ounce glasses of
non-alcoholic fluids daily.
Reduce alcohol comsumption.
Lose weight.
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Treament
NSAIDs
usual first-line treatment for gout
Improvement may be seen within four
hours, and treatment is recommended
for one to two weeks
Contraindicated if heart failure, GI
bleeding, kidney failure
Usually ibuprofen given due to less
severe side effects than other NSAIDs
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Ibuprofen
Bioavailability:

87%-100%
Metabolism: hepatic
Onset of action: 30 minutes
Excretion: urine
Half life: 1.5 3 hours

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Ibuprofen
Nonselective

inhibitor of
cyclooxygenase used to relieve
symptomatic stage of gout
Decreases the synthesis of
prostaglandins involved in mediating
inflammation, pain, fever, and swelling.
Risk for GI bleeding, thrombus
formation, hypertension.

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Colchicine
Bioavailability:

45%
Half life: 25 30 hours
Secretion: 60% feces - 20% kidneys
(contraindicated in kidney failure)
Metabolized partly by CYP3A4

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 Alternative

Colchicine

for those unable to

tolerate NSAIDs.
Inhibitsmicrotubulepolymerization
by binding totubulin, decreasing the
rate of mitosis.
Could lead to peripheral neuropathy
(common), anemia, hair loss, GI
disturbance.

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Glucocorticosteroids
Glucocorticoidshave been found as effective as
NSAIDsand may be used if contraindications
exist for NSAIDs.
Ex: Hydrocortisone, prednisone, dexamethasone.
Lead to improvement when injected in the joint
(infection MUST be excluded)
Common short-term side effects:

Weight gain.
Fluid retention.
Diabetes.
High blood pressure.
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Profylaxis
Xanthine

oxidase inhibitors: allopurinol,

febuxostat
Block uric acid production, and long-term
therapy is safe and well tolerated
Can be used in people with renal impairment
or urate stones. Usually for those with excess
urate acid production
Allopurinol has caused hypersensitivity
reactions (life threatening) in such cases, the
alternative drug, febuxostat, has been
recommended.
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Questions

1) A 45 year old woman comes to the physician

complaining of swelling and pain of her right
big toe, upon examinatino lab results reveal
uric acid levels of 7mg/dl. She can tolerate the
pain however its uncomfortable when dancing
at the disco, she has no hypertension or kidney
problems. Which drug is most appropriate?
A) Ibuprofen
B) colchicine
C) Febuxostat
D) Allopurinol
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Questions
2)

A 40 year old man comes comes to the

emergency ward with a skin rash. Upon
checking his medical history the physician
notices he is in gout medication. Which of
the following was the patient most likely
taking?
A) Prednisone
B) Febuxostat
C) Colchicine
D) Allopurinol
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Questions
3)

After the skin rash was treated

the physician will likely switch to
A) Hydrocortisone
B) Dexamethasone
C) Febuxostat
D) Colchicine

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