CLINICAL PRACTICE GUIDELINES

GOUTY
ARTHRITIS
Based on 2009 Philippine Clinical Practice Guidelines for the Management of Gout
Philippine Rheumatology Association
Objectives

Introduction
01 Gouty Arthritis and its
Pathogenesis
Gout Medications
CPG 03 Mechanisms of actions
Recommendations
02 Based on PRA 2008

4
 INTRODUCTION

Gout is the most prevalent form

of arthritis among the Filipinos
The prevalence of gout is 1.6%, a distinctive uptrend compared to
1991 when the prevalence was 0.5% , and in 1997 when the
prevalence was 0.13%.

Despite known quality indicators for treatment of gout, there is poor

adherence of physicians to these indicators. Interestingly,
inappropriate management of gout is a frequent occurrence even
with physician consultation.
 What is Gout? Gout is a metabolic disease that most often affects
middle-aged to elderly men and postmenopausal
women.

It results from an increased body pool of urate

with hyperuricemia. It typically is characterized
by episodic acute arthritis or chronic arthritis
caused by deposition of MSU crystals in joints
and connective tissue tophi and the risk for
deposition in kidney interstitium or uric acid
nephrolithiasis

Harrison's Principles of Internal Medicine, 19e

 URIC ACID

Uric acid is the end product of purine metabolism.

Most uric acid circulates as the urate anion, and serum urate concentrations normally
approach the theoretical limit of serum urate solubility. Human tissues have a very limited
ability to metabolize urate; thus, uric acid must be eliminated by the kidney and the gut
to maintain urate homeostasis.
 PURINES
A purine is an aromatic heterocycle
composed of carbon and nitrogen.

Purines include adenine and guanine, which

participate in DNA and RNA formation.
Purines are also constituents of other
important biomolecules, such as ATP, GTP,
cyclic AMP, NADH, and coenzyme A
Purine
Metabolism
Hyperuricemia

Hyperuricemia is defined as serum uric acid (SUA) level exceeding the limit of
urate solubility in the plasma, which is

7 mg/dl (416 umol/L) in men

6 mg/dl (357 umol/L) in pre-menopausal women *

Philippine Clinical Practice Guidelines for
the Management of Gout 2009

—Philippine Rheumatology Association

 PHASE 1
Asymptomatic Hyperuricemia

Defined as hyperuricemia in the absence of gouty arthritis and uric acid

nephrolithiasis

Hyperuricemia is a central feature of gout but does not inevitably and

absolutely cause it. The development of gout seems to be directly related
to the level of hyperuricemia, however, it is not absolute.
A threshold score of
≥8 classifies an
individual as having
gout

Sensitivity 92%
Specificity 89%
PHASE 2
Acute Gouty Arthritis

Acute gouty arthritis is defined in accordance with the American

College of Rheumatology (ACR) criteria for the classification of acute
attack of primary gout
PHASE 3
Intercritical Gout
Referred to as “interval gout”, applies to the asymptomatic periods
between gouty attacks or the period after the first attack.

● Lifestyle modifications
● Correct modifiable risk factors
● Start Colchicine 0.5mg BID to prevent future flares for 3-6 months
until normal SUA is achieved

WHEN TO START URATE LOWERING THERAPY?

2 EPISODES OF FLARE IN < 1 YEAR
Presence of tophaceous deposits
Presence of uric acid nephrolithiasis
Phase 4
Chronic Tophaceous Gout
Chronic Tophaceous Gout (CTG) occurs in untreated gouty arthritis,
characterized by persistent low grade inflammation of joints with
sporadic flares. Joint deformities seen are due to deposition of massive
urate crystals forming visible tophi
Management
Of Gout
Low Impact exercises and Activities
Gout Medications

Colchicine
Interferes with the inflammatory process by metaphase arrest
of multiplying Inflammatory Cells

Decreased neutrophil phagocytosis of urate crystals

Decreased Lysis of Neutrophils

Decreased Inflammation

Recommended dosing 0.5mg/tab 1 tab BID-QID

Gout Medications

NSAIDS
Inhibits COX

Inhibits PG synthesis

Reduces Inflammation
 Gout Medications
Allopurinol and
Febuxostat
Xanthine Oxidase Inhibitors

Allopurinol - Purine selective

Metabolized by the Kidneys

Febuxostat- Non-purine Selective

Metabolized by the Liver
 VS

There is no evidence demonstrating benefit with a hierarchical order

in the use of medications for acute gout. The Philippine guidelines
recommend that the choice of drug for acute gouty arthritis be
individualized taking into consideration drug efficacy, safety, and
cost.
Gout Medications

Uricosurics
Probenecid inhibits the tubular reabsorption of urate, thus increasing the
urinary excretion of uric acid in the urine and decreasing serum urate
levels.

Use of Uricosuric drugs increases the risk for developing

nephrolithiasis.
 PATIENT CENTERED
Gout being a lifelong but manageable illness , treatment should be
individualized centered on patient doctor-cooperation, taking into
consideration the patient’s current beliefs about his illness, medical history as
well as his financial capacity to maintain the planned management.
 FAMILY
FOCUSED
The Family of the patient should always be
involved in the management of the patient.
The family should be educated that gout can
be chronic and debilitating requiring support.
The family can also be a therapeutic ally in
providing the patient with the appropriate
diet, maintaining and sustaining medications
and providing emotional support.

Creator: kate_sept2004 | Credit: Getty Images

 COMMUNITY
ORIENTED
The patients health can be reinforced by
taking part in community health activities
such as routine exercises.

Joining such groups and communities

reinforces patient’s overall wellness and
compliance to the planned management by
having patients also with similar ailments
share their experiences.

Photography and the Spiritual Exercises by Br. Je

ff Pioquinto, SJ
Thank You