Gouty attacks, acute, treatment

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

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. 

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. 

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. 

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. 

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. 

A 55-year-old man presents with complaints of an acute gouty arthritis attack. His left big toe is red, swollen, and tender to the touch. This is his first attack. He has no history of peptic ulcer disease. His uric acid level is 8 mg/dL. Which of the following agents would you recommend for treatment ... 

Use Treatment of attacks of acute gouty Half-life ... 

Treatment with urate-lowering drugs is considered cost effective for acute gouty arthritis in patients having two or more attacks of gout per year. 

Eor treatment of acute gouty arthritis, indomethacin may be begun with a relatively large dose for the first 24 to 48 hours and then tapered over 3 to 4 days to minimize the risk of recurrent attacks. Eor example, 75 mg of indomethacin should be given initially, followed by 50 mg every 6 hours for 2 days and then 50 mg every 8 hours for 1 or 2 days. 

After the first attack of acute gouty arthritis or after the passage of the first renal stone, a decision to institute prophylactic therapy must be entertained. If the first episode was mild and responded promptly to treatment, the patient s serum urate concentration was elevated only minimally, and the 24-hour urinary uric acid excretion was not excessive (<1000 mg/24 hours on a regular diet), then prophylactic treatment can be withheld. Some patients never have a second attack or a second stone. Others may not experience a second gouty episode for 5 to 10 years. Therefore a wait-and-see attitude seems justified in patients who meet these conditions. ... 

Prophylactic therapy with low-dose oral colchicine, 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. Patients do not become resistant to or tolerant of daily colchicine, and if they sense the beginning of an acute attack, they should increase the dose to 1 mg every 2 hours in most instances the attack will abort after 1 or 2 mg of colchicine. If the serum urate concentration is within the normal range and the patient has been symptom-free for 1 year, maintenance colchicine may be discontinued. The patient should be advised, however, that discontinuation of the treatment program may be followed by an exacerbation of acute gouty arthritis. 

Probenecid/colchicine agents are used in gout. Probenecid inhibits the tubular reabsorption of urate, thus increasing urinary excretion of uric acid. Colchicine inhibits inflammation and reduces pain and swelling associated with gouty arthritis. They are indicated in treatment of chronic gouty arthritis when complicated by frequent, recurrent, acute attacks of gout. 

Probenecid is indicated for the treatment of hyperuricemia associated with gout and gouty arthritis and for the eievation and proiongation of piasma ieveis of peniciiiins and cephaiosporins. in gout, treatment shouid not begin untii an acute attack has subsided, it is not recommended in individuais with known uric acid kidney stones or biood dyscrasias or for chiidren under 2 years of age. 

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