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Bernadette C. Siaton, MD
Assistant Professor of Medicine
University of Maryland School of Medicine
Division of Rheumatology and Clinical Immunology
1 February 2014
Disclosures
none
Objectives
5 Gout Commandments
Hyperuricemia Gout
Goal sUA < 6
Use prophylaxis for at least 3 months after
initiating gout therapy
Do not stop gout medication unless patient is
showing evidence of drug toxicity or adverse
reaction
Ask your friendly rheumatologist for help!
4
Healthcare Utilization
Rheum
Non-rheum
P-value
Radiographs (%)
65
31
<0.05
Arthrocentesis (%)
75
34
<0.05
Time to improvement
(days)
3.6
6.6
0.06
Hospitalization (days)
7.4
14.7
0.08
8756
14750
Treat
Initiate
RESOLVE
(urate-lowering therapy)
MAINTAIN
(treatment to control sUA)
urate-lowering therapy to
achieve sUA <6
Use concomitant anti-inflammatory
prophylaxis for up to 6 mo to prevent
mobilization flares
Continue
Myth #1
% >50%
reduction in
pain
P value vs.
placebo
Adverse
Event Rate
% needing
rescue
medications
High dose
32.7%
0.034
76.9%
34.6%
Low dose
37.8%
0.005
36.5%
31.1%
Placebo
15.5%
n/a
27.1%
50.0%
Adverse Events
High Dose
Low Dose
Placebo
All GI Events
76.9
25.7
20.3
Diarrhea
76.9
23.0
13.6
Nausea
17.3
4.1
5.1
Vomiting
17.3
10
Improvement in pain @ 24
hours
High-dose
Low-dose
placebo
11
12
Myth #2
13
14
Maintenance Doses of
Allopurinol for Adults based
Maintenance Dose of
on CrCl
CrCl (mL/min)
Allopurinol
100mg every 3d
10
100mg every 2d
20
100mg
40
150mg
60
200mg
80
250mg
100
300mg
120
350mg
140
400mg
15
16
Pathophysiology
hypoxanthine
XO
xanthine
XO
urate
XO=xanthine oxidase
Allopurinol and febuxostat inhibit
xanthine oxidase and block uric acid
formation
17
Markel A. IMAJ, 2005.
17
Oxypurinol
allopurin
ol
Xanthin
e
Oxidase
Allopurinol
Hypersensit
ivity
Syndrome
oxypurino
l
Toxic
Epidermal
Necrolysis
StevensJohnson
Syndrome
18
Allopurinol Hypersensitivity
Syndrome
19
Relationship between
recommended allopurinol dose
and
< of6allopurinol in patients with renal
DosesUA
reduction
insufficiency may lead to under-treatment and
persistent hyperuricemia
no allopurinol
lower than recommended allopurinol dose
recommended allopurinol dose
higher than recommended allopurinol dose
20
Results
21
Is recommended dose of
allopurinol enough?
22
Is recommended dose of
allopurinol enough?
Limitations:
Retrospective study
Homogenous population (Maori/Pacific Islanders)
Cannot judge medication compliance
Conclusions:
23
Myth #3
24
CrCl (mL/min)
Maintenance Dose of
Allopurinol
100mg every 3d
10
100mg every 2d
20
100mg
40
150mg
60
200mg
80
250mg
100
300mg
120
350mg
140
400mg
25
Objective:
Determine the safety and efficacy of increasing
allopurinol dose above the proposed guidelines for
patients with gout
sUA
26
27
28
Conclusions
29
Febuxostat (Uloric)
FDA-approved 1966
FDA-approved 2009
Purine-selective XO Inhibitor
Non-Purine Selective XO
Inhibitor
Renal Metabolism
Liver Metabolism
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31
32
33
Adverse Events
Any Adverse
Event (AE)
Placebo
Febuxostat
80mg
Febuxostat
120mg
Febuxostat
240 mg
Allopurinol
300mg
Any AE
72%
68%
68%
73%
75%
Diarrhea
8%
6%*
7%*
13%**
6%
Hypertension
6%
5%
2%
4%
1%***
Neurologic sx
1%
2%*
2%*
7%**
2%
Muscle sx
5%
1%
<1%
1%
<1%***
34
Discussion
35
36
Treatment: Summary of
EULAR Recommendations
37
37
38
40
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QUESTIONS?
bsiaton@medicine.umaryland.edu
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