Management of acute gout Acute Gout

Gout is a disease of acute inflammatory arthritis, a painful disease that includes a highly detailed model of one, but could affect more than one joint.

Introduction:

The objective of addressing an attack of gout sharp end of pain and disability are fast and secure In the absence of treatment cured acute gouty arthritis in a few days to several weeks usually. Occurs improve more quickly when given a NSAID; where the symptoms clear up completely and more quickly when you begin treatment where the early use of many drugs in the management of acute attack of gout, although randomized trial data showed more than anti-inflammatory drugs Allastairoidah (NSAIDs), colchicine intra-articular or systemic glucocorticoids inhibitors of interleukin-beta 1 (B1).

While the end of the acute attack, the patient enters a period between the attacks intercritical, and sometimes that may require preventive treatment to prevent recurrent attacks of gout or chronic disease toffee.
And will now review the management of acute gouty arthritis. The detailed discussion for the prevention of recurrent gout after the departure of acute attack.

NSAIDs and enzyme inhibitors Alsichaelo oxygenase 2:


Despite the lack of studies of good quality on the role of NSAIDs in the treatment of gout, but it is a line management of most patients; where there is full recovery, or semi-full of pain and disability employment during a period of several days and up to a week, with attention to the need to avoid aspirin because of the paradoxical effect of salicylate on uric acid in the serum, resulting from global renal uric acid at doses as small (less than 2-3 g / day) and the occurrence of albuminuria, uric acid uricosuria when taking high doses of Alsaleslat.
Many studies have compared the different types of NSAIDs and there was no clear difference in effectiveness. In two large studies showed indomethacin and inhibitors of the enzyme Alsichaelo oxygenase - 2 eclecticism (Antirucoxab) a significant impact, where the back pain improved significantly during the 4 hours of the first dose.
Must also exercise caution in patients with a history of heart disease and vascular with the presence of several risk factors for injury coronal atheromatous, so that the use of inhibitors of the enzyme Alsichaelo oxygenase - 2 eclecticism and less NSAIDs, all lead to higher risk of myocardial infarction, and stroke stroke and heart failure.
Unless the patient has contraindications (gastrointestinal or cardiovascular or disease, renal or sensitivity) it is proposed to start using NSAIDs is eclecticism effective (Kalnibroudi and indomethacin) to relieve the symptoms of inflammation acute gouty, especially when starting treatment within 24 hours of onset of symptoms (according to the following algorithm).
Typical initial dose of Nabroxin is 500 mg twice a day, but for indomethacin is 150 mg per day given in 3 separate doses.
Because of repeated incidents of gastrointestinal intolerance associated with anti-inflammatory Allastairoidah, it must be reduced to half the dose as soon as the clinical and physical improvement to the patient, which usually takes about 3 days.


In practice, can then reduce the dose gradually to withdraw treatment within the next few days are safe, as most patients continue treatment with anti-inflammatory Allastairoidah until completely get rid of the acute attack, which takes about 70-10 days entirety.
Anakrsah for the attack, which extends to only a few days, it is necessary to determine the long-term drug scheme using anti-inflammatory agents with fewer gastrointestinal side effects (or Kalneboumyton Alsichaelo oxygenase enzyme inhibitors - 2 eclecticism).

For patients who have a high risk of a peptic ulcer or gastrointestinal bleeding, it is useful to add drugs for peptic ulcer as well as NSAIDs.

Colchicine:

Oral colchicine can be effective in the treatment of acute gouty arthritis, especially if giving him early after onset of symptoms and no matter what its use is limited when the emergence of side effects. In a small trial has randomly been ambulance 43 of the patients suffering from gout sharp ", which was confirmed through analysis of synovial fluid" and has been assigned to patients eating colchicine (1 mg, followed by 5 mg every two hours as stamina, or even get to respond fully ) or patients are given a placebo during the 24 hours after the onset of symptoms. Almost two thirds of patients who were treated after 48 Eulchesin improved compared with the other third, "The group was given a placebo"
In any case, all the patients who took colchicine appeared to have symptoms of diarrhea with / or vomiting after 24 hours the average time (and the average dose colchicine 6.7 mg), which appeared before the fallow in pain when the vast majority of patients
A result of these side effects have been saving oral colchicine for patients who can not afford the antibiotics or NSAIDs who used colchicine successfully in the past. Was among the many patients that the initial attacks can be stopped when dealing with oral colchicine during the initial bid.
Colchicine is usually given oral dose of 0.6 mg per hour until the occurrence of one of these things:
Mitigation of gouty inflammation or access to the maximum dose of 6 mg or gastrointestinal symptoms such as nausea - vomiting and diarrhea, especially, "which limits the additional use of colchicine." Once control of the inflammation, the following dosage can be reduced to 0.6 mg twice a day while continuing to eat if allowed digestive endurance so, until the completion of the attack.

There is an alternative treatment was recommended by a working group or the EULAR Standing Committee for International Clinical Studies and the treatment is Alkolchisen dose of 0.5 mg / 3 times a day. In the United States where Alkoulissin tablets 0.6 mg dose of readily available, this approach probably prefer to be dose colchicine 0.6 mg / 3 times a day
Colchicine in and Reddy:
Because of potential adverse effects of life-threatening Gan FDA in the United States has asked not to manufacture or import products into the veins, which include colchicine. Although intravenous formulations in pre-existing is not withdrawn, this drop-supply limits strictly and effectively end the use of colchicine by intravenous

And are taken into account to give intravenous colchicine in patients and paramedics who are unable to take oral medications. As mentioned above, the use of intravenous seriously restricted by systemic reactions, including the inhibition of bone marrow, liver necrosis, acute renal insufficiency and venous thrombosis in diffuse, seizures and even death. Tela hardened sharp reactions can occur during the leak, so must the provisions of colchicine portal vein.
Precautions for the use of intravenous colchicine have been published in order to minimize adverse consequences. In the 20 deaths as a result of the use of colchicine back inside and Reddy found that all patients who died had consumed doses in excess of recommended doses

Absolute Contraindications to address the acute attack of gout by the intravenous colchicine in include:

Meeting of renal and hepatic disease and creatinine clearance less than 10 ml / min and blocked roads outside the biliary liver.
And be given an initial dose ranging from 1-2 mg of colchicine and when necessary be given an additional dose of 1 mg after 6-12 hours. Should not exceed the total intravenous dose within 4-5 mg in 24 hours or during any attack.
Recently and with the availability of several alternative approaches, there are few cases in which colchicine is used inside and Reddy. Despite the fact that colchicine can reduce the inflammation of gout false, the potential danger of this approach led to the withdrawal of approval of the use of intravenous colchicine in the United States.

Where the availability of the product inside the vein, it must be taken into account when paramedics and patients with polyarticular Benkers or patients who are unable to take NSAIDs or who are unable to take medication orally. Entry must be monitored by the doctors of experts venous entry.
Commitment warnings mentioned above are necessary to avoid the toxicity that can be life-threatening

Glucocorticoid steroids:

These drugs can be injected in the affected joints or give it systemically, either orally or by means parenterals (injections).
Corticosteroids are injected intra-articular an acceptable option in patients who have a detailed or detailed Mtavean only, although the evidence on the usefulness is still weak and is still under experimentation. We consider this option preferable to systemic steroids in patients who can not take NSAIDs or colchicine.
Must be proof of diagnosis of acute gouty arthritis and end of any infection that is described by these drugs.
We use a typical triamcinolone acetonide 40 mg of the knee joint and lower doses for smaller joints, can also be used similar doses of Depo - methyl prednisone

- As for the sugary Systemic corticosteroids can be administered orally to patients who can not take NSAIDs or colchicine or patients are not candidates for injection because of the multiplicity of their affected joints.


The evidence on the effectiveness of steroids oral is still limited and is based on a clinical trial that showed that giving Prednisone or Albrdnazulun doses ranging from 30-50 mg per day (or steroids other) for a day or two days and followed a dose reduced to seven or ten days relieve acute symptoms as effectively as made by NSAIDs.

It must be pointed out that the potential for recurrent attacks of gout is common when steroids are stopped, especially among patients who previously suffered from many of the initial attacks, and emerged with a progressive in the short periods between shifts.



But in patients who do not accept the treatment of oral corticosteroids glucocorticoids injected intravenously or adrenal corticotropin hormone injected under the skin are options on the table ..
The instructions used in these treatments similar to win their favor followed in the oral treatment but we do not our preferred in acute gouty arthritis only if the venous cannula is connected already.

- Reflected the positive effect of ACTH in addition to induction of free corticosteroids, their impact on receptor melanocortin type the 3 in infected cells infected gouty, but evidence of their effectiveness is also limited, and proof of its success is one of the studies (ART) which have demonstrated that all the acute attacks that have been studied the recovery them during the five and a half days of treatment with ACTH Pal few side effects observed. Note that it may be the patient's need for more than a single injection of these drugs.

- There are several doses of ACTH have been proposed, with the use of 40-80 IU given twice daily for two days and then once a day for several days as required, in other studies has been proposed the use of 40 IU Khaknp one is repeated as needed or 25 IU Khaknp one when treating acute gout, which hit a single small detail.
Use of ACTH should be tuned according to the body the ability to absorb these drugs should also be avoided delays in dosing and for the achievement of all the previous goals should be monitored patient in the hospital or by any entity capable of ensuring his safety.

IL-1 inhibitors, a survey:

Incite urea crystals monosodium edit cytokines are the mass of pre-inflammatory white blood cells, leading to popular demonstrations, special sharp attack of acute gout. As the 'sponsored thiocyanates include Inter Lukin IL-1 released from monocytes in the synovium of the joint, leading to activation of the immune mechanism of action through the receptor TLR-4, TLR2 and thus activating the complex inflammatory ....
The IL-1 inhibitors to prevent accumulation of neutrophils as a result of injection into the crystals peritonitis in mice, and the encouraging results that have emerged in the mouse that Alkhadda the experience taught the union of anti-IL-1 receptor and Alanaknra anakinra in the treatment of acute gouty arthritis. In a study of 10 mice that failed or could not afford treatment alternative anti-inflammatory, received Annakinra (100 mg) subcutaneously for 3 days, and assessed through the painful joints and swollen, and during the assessment effective for relieving pain after 3 days and 30 days, the mice of the 10 responded to acute inflammatory arthritis in a positive (improvement in pain from 50-100%, is compatible with the clinical evaluation) within 24-48 hours and did not notice any side effects.
Results of this study open the confirmation study of random, but did not yet lived up to become the treatment recommendations, as is the case of treatment classic which shows results of clinical trials for the second phase and third treatment Balblasabo good results of protein anti-receptor Inter Lukin 1 where proven its ability to reduce levels of chronic pain and acute experience conducted on ten people ....

Special cases:

Hospital patients


The development of gouty arthritis in patients with acute hospitals (especially the post-operative patients) who do not take food through the mouth of the problems are relatively common.
Include treatment options in this case, intra-articular injection of steroids, intravenous, intramuscular or subcutaneous for ACTH and in rare cases intravenous colchicine. Has been elaborated in these treatments in the past.
The last stage of renal disease:
Although renal insufficiency predisposes to excessive uric acid in the blood, gout, people living with the patients and chronic renal disease or those with advanced stage renal disease are final and require hemodialysis to maintain the risk of gout is less casual than others. And those patients can be treated successfully using oral steroids or within the hinge. In general you should avoid Alkolchisen description of those patients, and there are fears that become worse renal function in patients who have not yet reached the stage of hemodialysis in the event description of NSAIDs
College transplantation patients
The gout of the important problems for patients with transplantation college, due to lower uric acid raised by the use of Alsaklosburnin. The treatment of gout in such circumstances a real challenge, partly because of complex drug interactions and serious. As a result, only the treatment of gout in patients growers member physicians with expertise in this field.



Patients treated with anti-acid hypersensitivity bloody urine


This treatment is used (Kaloloubeyoreynol and probenecid) in patients who suffer from repeated attacks of acute gouty arthritis, in order to prevent long-term, but it does not play any role in the effective treatment of gouty inflammation. When you start using these drugs, most experts believe it should not be stopped during the acute attack

It is common cause lack of appreciation of the difference between the treatments of anti-inflammatory and anti to the high uric acid by lengthening the phase-offs in patients who are supposed to be control of the gout, and in this case, treated the patient during the acute attack as any patient who does not practice treatments decreases the uric acid blood.


Summary and Recommendations:

Recommendations for the treatment of acute gout is limited by the lack of randomized trials (placebo - controlled).
Although, there are general recommendations based on available data can be summarized briefly following are:

• the goal of treatment in acute gout attack is a quick and speedy end to pain and disability.

• symptoms can be healed automatically and without medication during a period ranging from several days to several weeks, but get better faster if I give any kind of different types of anti-inflammatory and therefore in order to obtain the results of the urgent and full offer of early treatment of the patient.
• prefer to give NSAIDs in most people with acute gout the first line of treatment if you do not have any contra-indicated for this group of drugs.

• In the absence of data that suggests greater efficiency of a anti-inflammatory drugs (NSAIDs) compared to the rest, we often use a counter-effective (such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily) to reduce inflammation acute gouty and especially if they start treatment within 24 hours the onset of symptoms.

• In the event of an attack lasting several days, the matter may require longer treatment plan and preferred to use anti-inflammatory drug has few side effects on the stomach and duodenum (Kalneboumyton or COX2 selective inhibitor).


• often avoid aspirin because of the bad effects on serum acid urine (see paragraph NSAIDS - COX2 inhibitors at the top).

• Colchicine effective oral treatment for acute gout but often causes unwanted side effects.


• When patients who have intolerance to NSAIDS for treatment does not suit them or corticosteroids or who have already successfully use Colchicine Colchicine may be proposed for use with .. (See paragraph colchicine at the top).

• When patients can not take the NSAIDS or Colchicine is indicated to them not to use steroid injection intra-articular corticosteroids because of the multiplicity of affected joints have, we suggest the use of oral corticosteroids glucocorticoids; where we use often Prednisone dose range 30-50 mg per day for a day or two and then a dose of less for 7-10 days (see paragraph corticosteroids sugar on top).


• treatment options for patients not consenting to the use of oral treatments include glucocorticoids within the intravenous or intra-articular, the ACTH under the skin or muscle, and in cases where the use of intravenous colchicine in detail with caution and we use the following form:


In patients who can not take oral treatments and have a detailed or Mvslan afflicted inflammation was only to locate the exact injury is preferable to give an injection into the articular of glucocorticoids in the following form:
- Triamcinolone acid 40 mg for large joints Kmvsal knee.
- Triamcinolone 30 mg of the acid medium Kalmasm joints, ankle and elbow.
- 10 mg of articular small pieces.
- Or similar doses of Depo - methyl prednisone (see intra-articular injection at the top).

The patients who have multiple injuries articulated and veins can be made open to them in an easy and comfortable and do not have any contra-indicated for diabetic Akecraniat prefers to give them systemic glucocorticoids ways parenterals.

When determining the dose and frequency in this case, we rely on the property chosen, Valjrah model for methyl prednisone is 20 mg twice a day with ease wise dose with the start of improvement so as to maintain the dose minimum equal to 4 mg twice daily for 5 days (see Systemic drugs at the top).


The patients who are difficult to access the veins may be the use of ACTH intramuscularly or under the skin (see Systemic drugs at the top).


• that the use of intravenous colchicine has become more meaningful, was associated with serious side effects and bad (may lead to death) In 2008, the Food and Drug Administration FDA asked producers to stop production and shipment of intravenous forms of the drug (see colchicine at the top).

• For patients who are taking anti-hyper acid Paul serum due to exposure to previous episodes of gout should be alerted that this treatment is not sufficient it is possible that exposure to the symptoms of relapse from time to time and recommendations for treatment in acute attacks in these patients is the same when non-users of these drugs (see paragraph: Patients handlers of anti-uremic).