Gout secondary prevention: Difference between revisions
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== Secondary prevention == | == Secondary prevention == | ||
===== | Clinical practice guidelines are available: | ||
* American College of Physicians (ACP)<ref name="pmid27802508">{{cite journal| author=Qaseem A, Harris RP, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Denberg TD, Barry MJ | display-authors=etal| title=Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. | journal=Ann Intern Med | year= 2017 | volume= 166 | issue= 1 | pages= 58-68 | pmid=27802508 | doi=10.7326/M16-0570 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27802508 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28241287 Review in: Ann Intern Med. 2017 Feb 21;166(4):JC14] </ref> | |||
* American College of Rheumatology (ACR). https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Gout | |||
=== Life style modifications[edit | edit source] === | |||
* weight reduction reduces serum uric acid levels. | * weight reduction reduces serum uric acid levels. | ||
| Line 15: | Line 20: | ||
* Prevention and optimal management of chronic diseases and metabolic syndromes, cardiovascular events | * Prevention and optimal management of chronic diseases and metabolic syndromes, cardiovascular events | ||
===== Dietary changes[edit | edit source] ===== | |||
* Decreased levels of meat and sea food consumption and increased intake of low fat or non fat containing dairy products decreases gout attacks, where as foods rich in purine should be limited to moderate amounts. | * Decreased levels of meat and sea food consumption and increased intake of low fat or non fat containing dairy products decreases gout attacks, where as foods rich in purine should be limited to moderate amounts. | ||
* Increased dietary consumption of cherries decreases gout attacks. | * Increased dietary consumption of cherries decreases gout attacks. | ||
* Limiting high [[Fructose]] corn syrup intake reduces attacks of gout. | * Limiting high [[Fructose]] corn syrup intake reduces attacks of gout. | ||
=== Urate-lowering protocols === | |||
A nurse-driven protocol led to 95% of patients ( versus 30% in usual care) having a target serum uric acid level <360 μmol/L (6 mg/dL) within one year<ref name="pmid30343856">{{cite journal| author=Doherty M, Jenkins W, Richardson H, Sarmanova A, Abhishek A, Ashton D | display-authors=etal| title=Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. | journal=Lancet | year= 2018 | volume= 392 | issue= 10156 | pages= 1403-1412 | pmid=30343856 | doi=10.1016/S0140-6736(18)32158-5 | pmc=6196879 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30343856 }} </ref>. The protocol was: | |||
* Allopurinol: "started at 100 mg once per day and titrated upwards in 100 mg increments every 3–4 weeks according to serum urate concentrations, to a maximum of 900 mg once per day" | |||
* Flare prophylaxis: colchicine prophylaxis was optional | |||
* Results: more flares in the first year in the treatment group; less flares in treatment group during the second year | |||
A pharmacist-driven protocol led to 35% of patients ( versus 13% in usual care) having a target serum uric acid level <360 μmol/L (6 mg/dL) within 30 weeks<ref name="pmid27352414">{{cite journal| author=Goldfien R, Pressman A, Jacobson A, Ng M, Avins A| title=A Pharmacist-Staffed, Virtual Gout Management Clinic for Achieving Target Serum Uric Acid Levels: A Randomized Clinical Trial. | journal=Perm J | year= 2016 | volume= 20 | issue= 3 | pages= 15-234 | pmid=27352414 | doi=10.7812/TPP/15-234 | pmc=4991910 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27352414 }} </ref>. The protocol was: | |||
* Allopurinol: "100 mg/day (if the estimated glomerular filtration rate was less than 30 mL/min, the starting dose was 50 mg/day), unless there was a known allergy or other contraindication to allopurinol. After any change in ULT, subjects were instructed to return for laboratory assessment (sUA, alanine aminotransferase, complete blood cell count, and estimated glomerular filtration rate) in 2 weeks to 3 weeks, and report any adverse drug reactions or gout flares. Dose titration was in increments of 100 mg/day. The titration process was continued in an iterative fashion until a target sUA level was achieved and maintained" | |||
* After each dose change: "sUA, alanine aminotransferase, complete blood cell count, and estimated glomerular filtration rate" | |||
* Flare prophylaxis: "in most cases consisted of daily oral colchicine or any nonsteroidal anti-inflammatory drug" | |||
A target serum uric acid level of ''''<0.20 mmoles/liter (3.3 mg/dl)'''' for erosive gout achieved no clear benefit:<ref name="pmid34927391">{{cite journal| author=Dalbeth N, Doyle AJ, Billington K, Gamble GD, Tan P, Latto K | display-authors=etal| title=Intensive Serum Urate Lowering With Oral Urate-Lowering Therapy for Erosive Gout: A Randomized Double-Blind Controlled Trial. | journal=Arthritis Rheumatol | year= 2022 | volume= 74 | issue= 6 | pages= 1059-1069 | pmid=34927391 | doi=10.1002/art.42055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34927391 }} </ref> | |||
* Allopurinol: "in those in whom allopurinol was well tolerated, the allopurinol dose was increased every month by 50–100 mg daily (increment dependent on the eGFR), to a maximum dose of 900 mg daily" | |||
* Flare prophylaxis: "antiinflammatory prophylaxis against gout flares using colchicine (0.5 mg once daily) or naproxen (250 mg twice daily) was used for those who had experienced gout flares in the preceding 3 months" | |||
== References == | == References == | ||
Latest revision as of 20:32, 24 June 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Secondary Prevention strategies for Gout include dietary and life style modifications. Dietary and life style modifications are indicated for preventing gout flares. Consuming less purine rich food, fructose rich foods, cherries, vitamin C, increasing low fat dairy product consumption, avoiding red meat go in favour of reducing acute gout flares. Decreasing alcohol consumption, smoking cessation, weight loss, controlling underlying chronic conditions like Diabetes mellitus, Hypertension favour decrease in gout flares.
Secondary prevention
Clinical practice guidelines are available:
- American College of Physicians (ACP)[1]
- American College of Rheumatology (ACR). https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Gout
Life style modifications[edit | edit source]
- weight reduction reduces serum uric acid levels.
- Limiting alcohol intake and abstinence from alcohol in acute flares.
- All general lifestyle changes( like smoking cessation, increased physical activity, limiting telivision watching, eating healthy, etc.) that play role in control of chronic diseases are found to be more beneficial in gout
- Prevention and optimal management of chronic diseases and metabolic syndromes, cardiovascular events
Dietary changes[edit | edit source]
- Decreased levels of meat and sea food consumption and increased intake of low fat or non fat containing dairy products decreases gout attacks, where as foods rich in purine should be limited to moderate amounts.
- Increased dietary consumption of cherries decreases gout attacks.
- Limiting high Fructose corn syrup intake reduces attacks of gout.
Urate-lowering protocols
A nurse-driven protocol led to 95% of patients ( versus 30% in usual care) having a target serum uric acid level <360 μmol/L (6 mg/dL) within one year[2]. The protocol was:
- Allopurinol: "started at 100 mg once per day and titrated upwards in 100 mg increments every 3–4 weeks according to serum urate concentrations, to a maximum of 900 mg once per day"
- Flare prophylaxis: colchicine prophylaxis was optional
- Results: more flares in the first year in the treatment group; less flares in treatment group during the second year
A pharmacist-driven protocol led to 35% of patients ( versus 13% in usual care) having a target serum uric acid level <360 μmol/L (6 mg/dL) within 30 weeks[3]. The protocol was:
- Allopurinol: "100 mg/day (if the estimated glomerular filtration rate was less than 30 mL/min, the starting dose was 50 mg/day), unless there was a known allergy or other contraindication to allopurinol. After any change in ULT, subjects were instructed to return for laboratory assessment (sUA, alanine aminotransferase, complete blood cell count, and estimated glomerular filtration rate) in 2 weeks to 3 weeks, and report any adverse drug reactions or gout flares. Dose titration was in increments of 100 mg/day. The titration process was continued in an iterative fashion until a target sUA level was achieved and maintained"
- After each dose change: "sUA, alanine aminotransferase, complete blood cell count, and estimated glomerular filtration rate"
- Flare prophylaxis: "in most cases consisted of daily oral colchicine or any nonsteroidal anti-inflammatory drug"
A target serum uric acid level of '<0.20 mmoles/liter (3.3 mg/dl)' for erosive gout achieved no clear benefit:[4]
- Allopurinol: "in those in whom allopurinol was well tolerated, the allopurinol dose was increased every month by 50–100 mg daily (increment dependent on the eGFR), to a maximum dose of 900 mg daily"
- Flare prophylaxis: "antiinflammatory prophylaxis against gout flares using colchicine (0.5 mg once daily) or naproxen (250 mg twice daily) was used for those who had experienced gout flares in the preceding 3 months"
References
- ↑ Qaseem A, Harris RP, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Denberg TD, Barry MJ; et al. (2017). "Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians". Ann Intern Med. 166 (1): 58–68. doi:10.7326/M16-0570. PMID 27802508. Review in: Ann Intern Med. 2017 Feb 21;166(4):JC14
- ↑ Doherty M, Jenkins W, Richardson H, Sarmanova A, Abhishek A, Ashton D; et al. (2018). "Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial". Lancet. 392 (10156): 1403–1412. doi:10.1016/S0140-6736(18)32158-5. PMC 6196879. PMID 30343856.
- ↑ Goldfien R, Pressman A, Jacobson A, Ng M, Avins A (2016). "A Pharmacist-Staffed, Virtual Gout Management Clinic for Achieving Target Serum Uric Acid Levels: A Randomized Clinical Trial". Perm J. 20 (3): 15–234. doi:10.7812/TPP/15-234. PMC 4991910. PMID 27352414.
- ↑ Dalbeth N, Doyle AJ, Billington K, Gamble GD, Tan P, Latto K; et al. (2022). "Intensive Serum Urate Lowering With Oral Urate-Lowering Therapy for Erosive Gout: A Randomized Double-Blind Controlled Trial". Arthritis Rheumatol. 74 (6): 1059–1069. doi:10.1002/art.42055. PMID 34927391 Check
|pmid=value (help).