Managing Patients With Chronic Gout, Comorbidities

This video has been shared with permission from Consultant 360. Watch the original here.

In this video, Monica Richey, MSN, ANP-BC/GNP, discusses common comorbidities among patients with chronic gout, the role of comorbidities in treatment options for patients with chronic gout, and a case presentation of a patient with gout tophi and a fractured femur.

TRANSCRIPTION:

Monica Richey, MSN, ANP-BC/GNP: My name is Monica Richey. I'm a nurse practitioner, and I've been practicing in rheumatology since 2005. So, I'm about to make 20 years in the specialty. I love rheumatology. It's a very fun specialty. You always have a surprise in your day.

Consultant360: What comorbidities are common among patients with chronic gout?

Monica Richey: So, one of the most common is chronic kidney disease. That's really when we see patients coming in a lot sicker than the usual gout patients. They're usually on a diuretic. And if there is a combination of chronic kidney disease with heart failure, they're on very high doses of diuretics. Gout takes central space into that mix, because of mostly the diuretics don’t allow the kidneys to expel uric acid. So, those are usually our sicker patients. Diabetic patients sometimes tend to have gout. Those are usually the most complex when you have a patient with chronic kidney disease, a GFR of less than 30, and heart failure, those are the most common comorbidities that we see.

C360: What role do comorbidities play in the treatment options for patients with chronic gout?

Monica Richey: Everything will have more of a restricted use. For example, in chronic kidney disease, we don't use colchicine. If patients flare, they must use prednisone. But then if the patient has diabetes, we need to modulate the dose of the prednisone because it can increase the blood sugar. On the same hand, if patients have heart failure, we cannot use a very high dose of prednisone as well. It's a little bit more complex because then it is kind of like “What drugs can I use?” I cannot throw all other drugs at them at once because it would decompensate either one or the other. I have many patients who have CHF and CKD, and then we use very low-dose prednisone so as not to exacerbate the CHF. And allopurinol in low doses to try to control the gout. No febuxostat, no colchicine. So, mostly the two drugs that we use when we have a combination of those two diseases would be allopurinol and prednisone to try to control the disease.

For diabetics, it's a little bit easier if they don't have chronic kidney disease, but we do use prednisone in very low doses so as not to increase the blood sugar of those patients.

Obesity is common also. We see a lot of patients with gout and obesity. And then it's just a matter of, again, diet counseling. But most of the patients can tolerate the medications unless they have other comorbidities as well.

C360: Please provide a case presentation of a patient with chronic gout.

Monica Richey: I have a patient, for example, right now that we're trying to figure it out. This patient has failed allopurinol, failed febuxostat, and has very severe tophaceous gout. His load of tophi is so big that he had a fracture on his femur because of the tophi deposit. So, tophis are very destructive. “We think of that, oh, okay.

It's just a little bit of tophi.” No. They penetrate the bones, and they can fracture the bone as well. And in his case, we've decided to start with KRYSTEXXA to see if we can pull some of the uric acid out. And, unfortunately, he had an allergic reaction to the medication.

So then at this point, we're trying to use a combination of 2 agents, which is allopurinol and probenecid to see if we can start pulling some of this uric acid down Slowly, it's going to be a much slower process. KRYSTEXXA usually clears that in about 6 months to a year is all gone. This combination is Probably going to take 3 to 5 years, to take all the load of tophi that he has right now. But thankfully, he doesn't have kidney function issues. He doesn't have a heart function issue.

We tried the other medications before, but we failed. So now we're doing a combination of allopurinol with probenecid to see if we can pull more uric acid out faster to give him some release. So, that's one of the most challenging cases I have right now.

C360: Is there anything else you’d like to add?

Monica Richey: Gout treatment is not colchicine, it’s not just anti-inflammatory. The recommendation starts to tweak out if you have more than 3 flares a year, so if you're flaring more consistently… some patients have a flare once a year, like during summertime and barbecue or the holidays. If they're flaring more often, then we start chronic management. So, we come out of the colchicine and go into the allopurinol or febuxostat, as indicated. Please refer to us. We're happy to treat gout patients.

Always, always, always talk about diet with your patients.

There is a genetic component. So, in some patients you can ask and the father has it, grandfather has it. So they're more likely to have it. So you have the genetic component, but changing diet ddecreasesthe amount of flares in the uric acid tremendously, particularly abstaining from alcohol and seafood as well, which I understand sometimes is hard. And the uric acid level goal is less than 5 in all our gout patients to avoid flares.

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