1. Little Rheumatology gems for GP Trainees HDR 7/12/10 Hayley Faries, ST1 Rheumatology

2. Overview Case Pathophysiology + Management Some nuggets… – MTX monitoring – Important complication

3. Case 54yo male, BMI 30 Alcohol 30 units/wk c/o pain in left great toe – Acute onset over few hrs, very severe pain – Unable to tolerate bed covers touching foot

4. Gout Epidemiology – M>F 9:1, middle age, females more post menopausal Pathophysiology – Uric acid under secretion (diuretics, salicylates) Diagnosis – Mono-arthritis with High urate (usually) – Great toe/ metatarsal (50%), can affect wrists, elbows, ankles – Asymmetrical – Severity of pain – Prev attack

5. Gout (2) - assessment Confirm and exclude alternate diagnosis – Septic arthritis Assess severity (joints and function) Prev attacks and Rx tried Assess risk factors – Medication (diuretics, aspirin), Alcohol, BMI, High purine diet (liver, kidneys, seafood, yeast extract) – FHx (20% positive FHx) Identify assoc conditions: – Type II DM, Hypertension, cardiovascular disease Check urate levels – Often normal, may be high in 42%; still treat

6. Gout (3) – Acute Management NSAID (Diclofenac,Indomethacin, Naproxen) – Continue until 48hr after attack has resolved (7-10d) OR… If C/Is to NSAIDs – Colchicine 500 microg BD for 5-10days, then reduce to OD for 4-6 weeks. – If both C/I consider Prednisolone – If all of the above C/I… Paracetamol and Codeine – Do not stop Allopurniol in acute attack At DAY 10 or when acute attack GONE… consider ALLOPURINOL 100mg OD – Lowers level of Uric acid in blood

7. Management (4)- Allopurinol Indications: – 2 or more attacks in a yr or after 1 st attack in high risk people Tophi, xray changes, renal impairment – Long term duretic Risks: – Need to monitor U+Es every 3/12 in 1 st yr – Titrate (by 50-100mg) every few weeks to Uric Acid levels <300 Average dose 100 – 300mg OD – Check bloods 4 weeks after starting Rx – Co-prescribe NSAID low dose or Colchicine for 6 wks to prevent attack when starting Allpurinol – Consider need for GI cover

8. Gout (5) - Management Self help – Rest, Elevate limb, avoid any trauma, Ice pack No improvement/ Resistant Gout (i.e. received 4-5 days 1 st line Rx) – Review diagnosis, check compliance, encourage self care – Increase dose of medication or add Paracetamol – Other therapies to consider IM Depomedrone…Must be SURE it is gout! (not septic arthritis), benefit is that it lasts 2-3 months Prednisolone 20mg PO If very resistant, can do reducing course of Pred by 2.5mg/wk Intra-articular injection for flare if known gout

9. Follow Up and Referral RV pt at 4-6wks – Recheck Urate levels – Consider BP check/BM/lipid profile – Risk factor advice Diet, exercise, avoid dehydration, stop smoking, alcohol, weight – Consider advance prescription for future attacks Refer – Septic arthritis suspected – Diagnostic uncertainty, or systemically unwell – Allopurniol at max but still recurrent attacks – Complications (kidney stones) present

10. Methotrexate monitoring Indications to STOP: – Course of Abx/ any infection (restart when Abx finished) – ALT >3x normal – Low WCC, Low Neut. Safe to continue: – Lymphopaenia – ALP rise – Hb drop 9-10 not likely 2ary to MTX Though, may need to investigate cause for drop in Hb

11. Digital Ulcers

12. In-patient cases – Digital Ulcers 48yo Scleroderma +Raynauds - Infected digital ulcers – Think osteomyelitis 42yo Sjogrens syndrome - Wet gangrene toe – IV Iloprost (vasodilatory) and IV Abx Digital Ulcers for GPs – Complication of CTD – Fingers/Toes/ any pressure area – Think infection with redness/pain/discharge -> ABX! – Take swab – Conservative advice

13. Thank you, any questions?