QD 78- My Acute Gout Save

Welcome to QT clinic brought to you by RheumNow live. I'm Jack Cush from rheumnow.com. Our case today is my acute gout, also known as why I would never use colchicine. So a patient comes in. Let's say he's 50.

Let's say he's Caucasian, and let's say he has a diagnosis of gout. His diagnosis of gout was made three years ago when he presented with podagra and a uric acid of 8.5 and then went on to have several attacks over the next few years. Each attack lasting five to seven days, usually being the MTP, the tarsus, and then lastly being the knees. He comes into clinic presenting with an olecranon bursitis after having had a recent, pedagra attack and after having stopped allopurinol, which was star started in him to obviously reduce his incidence of gouty attacks. So we have a fellow presenting with an acute attack, now an acute bursitis.

It's red. It's swollen. It's tender. It may have some nodular stuff on the inside of that olecranon bursa, which is fluctuant, suggesting he may have a total body urate load that's higher than we may think. And it wouldn't be surprising if we got labs today, which we did, that would show that his uric acid is normal because forty percent of acute attacks will have a normal uric acid.

So he has been sort of self managing this with, an old prescription of colchicine. He's been told to take it one pill, when he gets an attack and then take it an hour later, and then he can take a third one, but no more than three a day until he is better. And he says that's worked kinda well for him. He's gotten a little bit of diarrhea. He's run out of his prescriptions.

He hasn't gone back to his doctor. And the question is, and how would I manage him? How did I manage him? Number one, I stopped using colchicine when colchicine went from 4¢ a pill to $5.50 a pill, $5.50 a pill. And now that it's generic, it's down to about a buck a pill, which is still about 20 times too expensive for a drug that's been around since for as long as dirt, basically.

It is, it's a time honored, two hundred years of showing that gout, that colchicine works, you know, when the when you give it as some kind of bark extract or as a pill, that you can buy from the pharmacy. But it also has, you know, two hundred years of a storied history of toxicity, Even homicide and suicide by colchicine IV colchicine was taken off the market because it was too toxic. And, frankly, you don't need colchicine to manage gout. It's an historic drug. I don't use historic drugs to moderate to to manage my modern day medical problems.

If I did, I would just be writing prescriptions for penicillin penicillin, colchicine, and steroids, and I write for almost none of those. There's some there are drugs that are so much better, so much more efficient. So an acute gouty attack in my book should be managed by, one, confirming the diagnosis. Two, using steroids. You can use intramuscular steroids.

You can use oral steroids. Use a big dose. Use it for a few days. If you get it early enough, you need treatment for three days, five days. If you get it after they've been going on for, you know, five to seven days, you might need it for seven to ten days to make a attack go away.

I tend to use prednisone twenty milligrams a day. I can go as high as thirty. I can start out with a Decadron shot followed by fifteen, twenty milligrams a day until they're better, and then you have to figure out what you're gonna do after the acute gout attack. If I can't use steroids because they're a brittle diabetic, because they can't take steroids for some reason, then nonsteroidals are highly effective. You do worry a little bit about renal toxicity, destabilization of of unstable heart disease and and heart failure.

But, honestly, they're just gonna get five days of a nonsteroidal, and that usually works really well. Use big boy anti inflammatory doses. That's fifteen hundred of of naproxen, at least a thousand of naproxen. Come on. None of this two twenty stuff.

And then if you need to, I wouldn't use a short acting nonsteroidals like ibuprofen. I might use meloxicam fifteen milligrams once a day until they're better, etcetera. So it's basically steroids, steroids, steroids, nonsteroidals. And if you can't use that, you could use colchicine. IV is not available anymore, and you gotta give enough of it probably to cause diarrhea.

But, nonetheless, you could use it, but I honestly haven't used colchicine in a long time. And partly because of the ridiculousness of pricing, partly because of the toxicity profile. I do have a few patients who do take colchicine usually for an autoinflammatory disease like familial Mediterranean fever. I send them to Canada, to one of the Canadian pharmacies asked me. I'll tell you which one I might use.

I don't wanna say it here. Bernie Sanders may may either endorse me, and, someone else may crucify me for sending my patients to Canada where the drugs are illegal and, God knows, very harmful and illegally made. Well, they're just the same thing as we can get here. You can get drugs fairly cheap there. Cheap ways of getting drugs would be to go to Canada.

Another way would be to, actually use a a good Rx card or to actually call the pharmacist and figure out a cheaper way to get whatever drug that it is that you want. Anyway, that's it for this edition of QD Clinic. RheumNow, has a fabulous session on, spondylitis that is going to be led on on Sunday by Atul Daydar. He's gonna talk about all the latest updates on new therapies, IL twenty three, IL seventeen. It's really quite impressive.

Arti Kavanaugh is gonna talk about something you've never heard of but would always wanted to know, and that is enteropathic arthritis, meaning IBD associated arthritis, diagnosis, management, clinical considerations. And then Walter Miksimovich from Edmonton is gonna talk to us about imaging, both radiographic and MRI imaging and all the mystery around SI joint readings on MRI. There's a lot of new information there. Again, come to Fort Worth on this meeting, 03/13/1415 for a fabulous set of lectures, including ones on spondyloarthritis.