Gouty arthritis, acute treatment

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

Indomethacin is available for the short-term treatment of acute gouty arthritis, acute pain of ankylosing spondylitis, and osteoarthritis. An injectable form to be reconstituted also is available as the sodium trihydrate salt for IV use in premature infants with patent ductus arteriosus. Because of its ability to suppress uterine activity by inhibiting prostaglandin biosynthesis, indomethacin also has an unlabeled use to prevent premature labor. 

Daily doses of 3-8 mg (6-8 times 0.5-1.0 mg) are used for the treatment of acute gouty arthritis. For prophylaxis, daily doses of 0.5-1.5 mg are used, but the use of colchicine for prophylaxis is controversial. 

Certain drugs bind to microtubules and thus interfere with their assembly or disassembly. These include colchicine (used for treatment of acute gouty arthritis), vinblastine (a vinca alkaloid used for treating certain types of cancer), paclitaxel (Taxol) (effective against ovarian cancer), and griseoflilvin (an antifungal agent). 

Treatment of gout involves (1) acute relief of a gouty arthritis attack and (2) in some patients long-term maintenance treatment to prevent future attacks. 

Allopurinol is well absorbed with a short half-life of 2 to 3 hours. The half-life of oxypurinol approaches 24 hours, allowing allopurinol to be dosed once daily. Oxypurinol is cleared primarily renally and can accumulate in patients with reduced kidney function. Allopurinol should not be started during an acute gout attack because sudden shifts in serum uric acid levels may precipitate or exacerbate gouty arthritis. Rapid shifts in serum uric acid can change the concentration of monosodium urate crystals in synovial fluid, causing more crystals to precipitate. Thus some clinicians advocate a prophylactic dose of colchicine (0.6 mg/day) during initiation of antihyperuricemic therapy. Acute episodes should be treated appropriately before maintenance treatment is started. 

When joint aspiration is not a viable option, a presumptive diagnosis of acute gouty arthritis may be made on the basis of the presence of the characteristic signs and symptoms, as well as the response to treatment. 

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. 

FIGURE 1-1. Treatment algorithm for acute gouty arthritis. (NSAID, nonsteroidal antiinflammatory drug.)... 

TABLE 1-1 Dosage Regimens of Nonsteroidal Antiinflammatory Drugs for Treatment of Acute Gouty Arthritis... 

Prophylactic treatment can be withheld if the first episode of acute gouty arthritis was mild and responded promptly to treatment, the patient s serum urate concentration was only minimally elevated, and the 24-hour urinary uric acid excretion was not excessive (less than 1,000 mg/24 hours on a regular diet). 

If the patient had a severe attack of gouty arthritis, a complicated course of uric acid lithiasis, a substantially elevated serum uric acid (greater than 10 mg/dL), or a 24-hour urinary excretion of uric acid of more than 1,000 mg, then prophylactic treatment should be instituted immediately after resolution of the acute episode. 

Patients with acute gout should be monitored for symptomatic relief of joint pain as well as potential adverse effects and drug interactions related to drug therapy. The acute pain of an initial attack of gouty arthritis should begin to ease within about 8 hours of treatment initiation. Complete resolution of pain, erythema, and inflammation usually occurs within 48 to 72 hours. 

For the treatment of chronic gouty arthritis when complicated by freguent, recurrent acute attacks of gout. 

Indomethacin (Indocin) is used in the treatment of acute gouty arthritis, rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis. It is not recommended for use as a simple analgesic or antipyretic because of its potential for toxicity. While indomethacin inhibits both COX-1 and COX-2, it is moderately selective for COX-1. It produces more CNS side effects than most of the other NSAIDs. Severe headache occurs in 25 to 50% of patients vertigo, confusion, and psychological disturbances occur with some regularity. GI symptoms also are more frequent and severe than with most other... 

Initial treatment of gout and its associated hyperuricemia must involve therapy directed toward terminating the painful inflammatory process that is a prominent feature of acute gouty arthritis. A variety of nonsteroidal antiinflammatory compounds (e.g., in-... 

Colchicine, an alkaloid obtained from the autumn crocus, has long been used and is relatively selective for the treatment of acute gouty arthritis. Unlike many of the newer agents for use in gout, colchicine has minimal effects on uric acid synthesis and excretion it decreases inflammation associated with this disorder. It is thought that colchicine somehow prevents the release of the chemotactic factors and/or inflammatory cytokines from the neutrophils, and this in turn decreases the attraction of more neutrophils into the affected area (Fig. 37.1).The ability of colchicine to bind to leukocyte microtubules in a reversible covalent complex and cause their depolymerization also may be a factor in decreasing the attraction of the motile leukocytes into the inflamed area. 

The major use of colchicine is as an antiinflammatory agent in the treatment of acute gouty arthritis it is not effective in reducing inflammation in other disorders. It also can be used to prevent attacks. Since colchicine is so rapidly effective in relieving the acute symptoms of gout (substantial improvement is achieved within hours), it has been used as a diagnostic aid in this disorder. 

Phenylbutazone (Butazolidin, Tandearil) (see Chapter 36) also displays antipyretic, analgesic, and antiinflammatory activity. In addition, it possesses some uricosuric potency and therefore is widely used for the treatment of acute attacks of gouty arthritis, in which it is about equal to colchicine in effectiveness. Although the drug does promote the renal excretion of uric acid, its usefulness is generally attributed to its antiinflammatory actions. 

The most widely used agent for the treatment of acute gouty arthritis is... 

Unlabeled Uses Treatment of acute gouty arthritis, vascular headache... 

Although colchicine is more specific in gout than the NSAIDs, NSAIDs (eg, indomethacin and other NSAIDs [except aspirin]) have replaced it in the treatment of acute gout because of the troublesome diarrhea sometimes associated with colchicine therapy. Colchicine is now used for the prophylaxis of recurrent episodes of gouty arthritis, is effective in preventing attacks of acute Mediterranean fever, and may have a mild beneficial effect in sarcoid arthritis and in hepatic cirrhosis. Although it can be given intravenously, this route should be used cautiously because of increased bone marrow toxicity. 

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