Gout Historically known as the “disease of kings” due to its association with rich foods, alcohol and wealth, gout is common today among New Zealanders of a wide socioeconomic range. Gout affects four times as many men than women and Maori and Pacific Island men are disproportionately affected (10–15% affected compared with 1%–2% of men with European ancestry). Gout is uncommon in women until after menopause. Gout is a form of arthritis that can easily be mistaken for a bacterial cellulitis (an infection in the first two layers of skin). An acute attack causes sudden intense swelling, redness and warmth in a joint, most commonly the big toe, although it can occur in the ball of the foot, instep, ankle, knee, wrist, tip of the elbow or fingers. Gout is considered the most painful of all types of arthritis with the patient unable to weight-bear or wear shoes if the gout is present in the foot. In addition to localised pain, a person with gout may also have a mild fever or feel unwell. Left untreated, gout can lead to permanent joint destruction and kidney damage and can double the risk of a heart attack or stroke. Causes of gout Although the most common reason gout occurs is due to high uric acid levels (hyperuricaemia) in the blood, the relationship between uric acid and gout is not clear-cut, as many people with hyperuricaemia never develop gout, while some patients with repeated gout attacks have normal or low blood uric acid levels. An inherited tendency to excrete less uric acid through the kidneys is the primary reason people have high uric acid levels. See table opposite page for other common causes of hyperuricaemia. Gout occurs when uric acid accumulates in a joint and saturates out to form tiny needle-shaped crystals. The body mounts an inflammatory response to the crystals in that joint leading to the characteristic gout symptoms of inflammation and pain. Most early gout attacks resolve spontaneously after seven to 10 days, but in practice the severe pain usually forces people to seek treatment earlier. The length of time between attacks can vary widely, with some patients only ever having one attack. For the majority of patients, a second attack will occur within a year. If a patient’s uric acid level remains high (>0.36mmol/L) despite the patient being symptom free, there can be ongoing joint inflammation which results in joint damage and tophi formation. Tophi Years of unresolved gout can lead to chronic tophaceous gout. Tophi are firm white translucent nodules that can occur around the joints or on the external ear and arise from the deposition of urate crystals. They usually take at least five to 10 years after the initial attack to develop. As well as causing joint destruction, they are disfiguring and also cause physical hindrance. Although effective treatment can lead to the regression of tophi, they are far more difficult to manage once they have developed. Risk factors for gout Research has located a specific genetic variant within a gene that doubles the risk of gout in Europeans and increases the risk by more than five times in people TREATMENT OPTIONS Category Examples Comments Acute gout [PHARMACY ONLY] or [PRESCRIPTION](higher dosages) Non-steroidal anti-inflammatory drugs (NSAIDs) eg, diclofenac, naproxen [PRESCRIPTION] Oral corticosteroids eg, prednisone Intra-articular corticosteroids, eg, methylprednisolone, triamcinolone [PRESCRIPTION] eg, Colchicine (Colgout) Give regularly until severe pain reduces then decrease dosage (ie, diclofenac 75mg bd or naproxen 500mg bd initially). May not be suitable for some people taking other medicines or with some medical conditions (eg, asthma, kidney disease), and should be discontinued if stomach upsets, increased bruising or prolonged bleeding occur. See Reference section, OTC Medicines – Precautions. Alternative if NSAIDs are contraindicated. Infection should be excluded before using. Intra-articular corticosteroids may be considered if gout localised to single joints. No longer considered first-line treatment for acute gout, but may be used as an alternative treatment, or as an adjunct to NSAID treatment. Can also be used as a prophylactic. Overdosage can cause diarrhoea. Prevention of gout [PRESCRIPTION] eg, allopurinol [PRESCRIPTION] eg, febuxostat (Adenuric) eg, benzbromarone [PRESCRIPTION] eg, probenecid (Probenecid AFT) Usually started at least two weeks after an acute gout attack. 1%–2% of people develop a rash (more common in patients with renal impairment). Regular allopurinol taken before the start of an acute attack should be continued. Available on special authority for those with special conditions, contraindications, intolerance, or who have failed to respond to treatment with other preventative drugs. Useful for patients with normal renal function and urate under-excretion. May be used in combination with allopurinol in certain people (ie, with persistent hyperuricaemia). Contraindicated in patients with a history of renal stones. Ensure good fluid intake (eight glasses of water per day). If a patient has been taking probenecid regularly at the time of an acute attack, it should be continued. PharmacyToday A part of your everyday Page 78 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION of Maori or Pacific ancestry. People who drink soft drinks sweetened with high fructose corn syrup (HFCS) or consume diets rich in fruit or fruit juice are also at increased risk. In addition, certain medical conditions (eg, type 2 diabetes, kidney problems, elevated blood pressure), some medicines (eg, diuretics, cytotoxics), large intakes of purine-rich foods or alcohol (particularly beer) and joint injury also contribute to the risk. Treating a gout attack Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended first line (unless contraindicated) as pain relief for acute attacks of gout (see Treatment Options previous page). Corticosteroids or low dose colchicine can be used as an alternative to NSAIDs. Any medicine used to treat acute attacks should be taken at the first sign of an attack at an effective dose. In most people, pain and inflammation caused by the gout can be controlled within 12–24 hours and treatment discontinued after a few days. Drugs used for gout attacks have no effect on reducing uric acid levels and all customers with symptoms suggestive of gout should be referred to a doctor for consideration of allopurinol or probenecid. Early prevention of gout, before the onset of tophi, erosive disease and renal impairment, is vital. Preventing gout Most experts agree preventive therapies should aim to reduce serum uric acid concentration to below 0.36mmol/L (some experts aim for as low as
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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