Anti-Inflammatory Case Study of Mr. Y
Based on the presenting symptoms and lab findings, Mr. Y will most likely be diagnosed with Gout. Gout is a type of arthritis that causes painful and stiff joints; caused by the build-up of uric acid. It often starts in the big toe and can also cause lumps under the skin and kidney stones. Gout is a rheumatic disease that results from an excess body burden of uric acid, or hyperuricemia, which commonly manifests as recurrent episodes of acute joint pain and inflammation secondary to the deposition of monosodium urate crystals, or tophi, in the synovial fluid and lining. Hyperuricemia is caused by an increased production or a decreased excretion of uric acid, or both.
Pharmacologic Plan of the Management of Acute Gout
The diagnosis and treatment of gouty arthritis is determined by the severity of pain, duration of attack, and extent of joint involvement. Pain assessment is commonly based on a visual analogue scale of 0 to 10 where ?4 is mild, 5 to 6 is moderate, and ?7 is severe. The duration of gouty arthritis is measured from the onset of gouty pain where 36 hours is late. The extent of an acute gouty arthritis attack is determined by the number of active joints. Gouty arthritis should be treated with pharmacologic therapy within 24 hours of attack and for up 7 to 10 days.2,7 ULTs should be continued during an acute attack (Khanna, 2012). Monotherapy with nonsteroidal anti-inflammatory drugs (NSAIDs), systemic corticosteroids, or colchicine is recommended for mild-to-moderate pain where only one or a few small joints are affected. In a peer-reviewed study in a February 3rd issue of New England Journal of Medicine, (Medscape, 2011) the first-line agents for acute attacks are NSAIDs and colchicines, and adjunctive measures include applying ice to and resting the affected joint. NSAIDs should be avoided in patients with renal or hepatic impairment, bleeding disorder, congestive heart failure, or allergy and may increase the risk for adverse thrombotic and gastrointestinal tract events.
Pharmacologic Plan of the Management of Chronic Gout
Combination therapy is recommended for poly-articular attacks or an attack affecting multiple large joints that induce severe pain. Non-steroidal anti-inflammatory drugs, and/or corticosteroids are recommended. Colchicine exerts its effects by reducing lactic acid production by leukocytes, which in turn decreases uric acid deposition and reduces phagocytosis, with abatement of the inflammatory response. Although an older drug, colchicine just recently obtained an FDA indication for use in patients with acute gout (Colerys, 2012). Colchicine should be instituted only in early or well-established gouty attacks. In a recent randomized trial, low-dose colchicine (1.8 mg over 1 h) yielded both maximum plasma concentration and early gout-flare efficacy comparable to high-dose colchicine (4.8 over 6 h), with a safety profile indistinguishable from that of placebo (Terkeltaub, 2010). Corticosteroids are recommended by the ACR for monotherapy, but these agents are generally reserved for patients who cannot tolerate either colchicine or NSAIDs due to their systemic adverse effects (Khanna, et al, 2012).
ACP (2017) recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks, In the peer reviewed article, Management of Acute and Recurrent Gout: A Clinical Practice Guideline; although evidence supports the benefits of using urate-lowering therapy for shorter durations to reduce gout flares, the benefits of long-term use (?12 months), combination urate-lowering therapy will be utilized . In cases of recurrent gout or problematic gout, shared decision making with the patient is warranted to review possible harms and benefits of long-term urate-lowering therapy.
Key Elements of the Educational Plan for Management of Acute and Chronic Gout
Lifestyle recommendations include regular exercise to achieve physical fitness, weight loss to achieve a body mass index that promotes general health, maintaining proper diet, hydration, and smoking cessation. Foods that patients should avoid include organ meats high in purine content, high-fructose corn syrup–sweetened beverages, alcohol overuse, and alcohol consumption during gouty attacks. Servings of red meats, seafood, fruit juices, table sugar, and salt should be restricted (Khanna, 2012).
American College of Physicians (ACP). (2017). Management of Acute and Recurrent Gout: A Clinical Practice Guidelines. Retrieved June 10, 2018 from http://annals.org/aim/fullarticle/2578528/management-acute-recurrent-gout-clinical-practice-guideline-from-american-college
Colcrys (colchicine) (2012). Deerfield, IL: Takeda Pharmaceuticals America, Inc.
Khanna, D., Fitzgerald, J., Khanna, P., et al. (2012). American College of Rheumatology. American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64:1431-1446. Burbage, G. (2014). Gout: clinical presentation and management. Nursing Standard, 29(2), 50-56. doi:10.7748/ns.29.2.50.e8464
Medscape (2011). The diagnosis and treatment of gout. The New England Journal of Medicine. February 3 issue. Retrieved March 10, 2018 from www.medscape.com
Terkeltaub RA, Furst DE, Bennett K, et al. High versus low dosing of oral colchicine for early acute gout flare: twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62:1060-1068.
Anti-Inflammatory Case Study of Mr. Y