Acute attacks

Colchicine provides dramatic relief from acute attacks of gout. The effect is sufficiently selective that the drug has been used for diagnostic purposes, but the test is not infallible. Colchicine also has an established role in preventing and aborting acute attacks of gout. However, its toxicity and the availability of alternative agents that are less toxic have substantially lessened its usefulness. 

Great care should be exercised in prescribing colchicine for elderly patients, and for those with cardiac, renal, hepatic, or gastrointestinal disease. In these patients and in those who do not tolerate or respond to colchicine, indomethacin or another nonsteroidal anti-inflammatory agents (NSAID) is preferred. 

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Nitroglycerin has long been used for the treatment of acute attack of angina pectoris, and its stable analogs are available to prevent the anginal attack. Nitrovaso-dilators such as sodium nitropmsside liberate NO from their molecules in the tissue (thus, called NO donors) and elicit actions via cyclic GMP like those seen with endogenously synthesized NO. 

Drugp indicated for treatment of gout may be used to manage acute attacks of gout or in preventing acute attacks of gout (prophylaxis). 

Drink at least 10 glasses of water a day until Hie acute attack has subsided. 

Discuss important points the nurse should consider when administering colchicine to a patient with an acute attack of diarrhea. 

Montelukast—Take once daily in the evening, even when free of symptoms. Contact physician if the asthma is not well controlled. This drug is not for the treatment of an acute attack. Avoid taking aspirin and the NSAIDs while taking montelukast. 

When taking nitroglycerin for an acute attack of angina, sit or lie down. To relieve severe lightheadedness or dizziness, lie down, elevate die extremities, move die extremities, and breadie deeply. 

Activation of factor XII and cleavage of high molecular weight kininogen during acute attacks in hereditary and acquired Cl-inhibitor deficiencies. Immunopharmacology 1996 33 361-364. 

Snow V, Weiss K, Wall EM, Mottur-Pilson C. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med 2002 137 840-849. 

Nonsteroidal anti-inflammatory drugs, colchicine, or corticosteroids are used for acute attacks. Selection depends on several patient factors, especially renal function. 

The serum uric acid level often is elevated but may be normal during an acute attack. 

If the diagnosis is an acute attack of gouty arthritis, what treatment plan would you outline for this patient ... 

Do not start antihyperuricemic therapy within 4 weeks of an acute attack. 

Corticosteroids (e.g., beclomethazone, flunisolide, triamcinolone) have anti-inflammatory and immunosuppressant actions. These drugs are used prophylactically to prevent the occurrence of asthma in patients with frequent attacks. Because they are not useful during an acute attack, corticosteroids are prescribed along with maintenance bronchodilators. These drugs are also administered by inhalation. Cromolyn is another anti-inflammatory agent used prophylactically to prevent an asthmatic attack. The exact mechanism of action of cromolyn is not fully understood however, it is likely to involve the stabilization of mast cells. This prevents the release of the inflammatory mast cell mediators involved in inducing an asthmatic attack. Cromolyn has proven effective in patients with exercise-induced asthma. 

The first-line drug for treating an acute attack of reentrant supraventricular tachycardia (SVT) is... 

Acute attacks of gouty arthritis are characterized by rapid onset of excruciating pain, swelling, and inflammation. The attack is typically monoarticular... 

The goals in the treatment of gout are to terminate the acute attack, prevent recurrent attacks of gouty arthritis, and prevent complications associated with chronic deposition of urate crystals in tissues. 

Therapy should be initiated with maximum recommended doses for gout at the onset of symptoms and continued for 24 hours after complete resolution of an acute attack, then tapered quickly over 2 to 3 days. Acute attacks generally resolve within 5 to 8 days after initiating therapy. 

Colchicine is an antimitotic drug that is highly effective in relieving acute gout attacks but has a low benefit-toxicity ratio. When colchicine is started within the first 24 hours of an acute attack, about two-thirds of patients respond within several hours. The likelihood of success decreases substantially if treatment is delayed longer than 48 hours after symptom onset. 

Corticosteroids may be used to treat acute attacks of gouty arthritis, but they are reserved primarily for patients with a contraindication or who are unresponsive to NSAID or colchicine therapy. Patients with multiple-joint involvement may also benefit. 

Colchicine given in low oral doses (0.5 to 0.6 mg twice daily) may be effective in preventing recurrent arthritis in patients with no evidence of visible tophi and a normal or slightly elevated serum urate concentration. The oral dose should be reduced to no more than 0.6 mg daily or every other day in patients with renal or hepatic dysfunction. Treated patients who sense the onset of an acute attack should increase the dose to 1 mg every 2 hours in most instances, the attack aborts after 1 or 2 mg. Discontinuation of prophylaxis may be attempted if the serum urate concentration remains normal and the patient is symptom-free for 1 year. 

Colchicine, 0.5 mg twice daily, is sometimes given during the first 6 to 12 months of antihyperuricemic therapy to minimize the risk of acute attacks that may occur during initiation of uric acid-lowering therapy. 

All patients should be treated for acute attacks and maintained on prophylactic treatment for 6 to 12 months after the initial episode. Aggravating factors such as alcohol or cocaine use and cigarette smoking should be stopped. 

Data from Snow V, Weiss K, Wall EM, Mottur-Pilson C. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med 2002 137 840-849 and Diamond M, Cady R. Initiating and optimizing acute therapy for migraine The role of patient[Pg.614]

Drug therapy of an acute attack typically consists of an osmotic agent and secretory inhibitor (e.g., /1-blocker, a2 agonist, latanoprost, or CAI), with or without pilocarpine. 

On the other hand, insufficient NO production also causes serious medical problems. Many diseases such as hypertension, atherosclerosis and restenosis involve a deficiency of NO production. Therefore, a compound that can release NO under specific conditions can be used therapeutically to palliate NO underproduction. In fact, the best known NO donor, glyceryl trinitrate, has been used for over a century to relieve acute attacks of angina pectoris. 

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