winterallsummer Posted December 7, 2013 Share Posted December 7, 2013 Hello, I am currently on my FM medicine but saw several cases of gout as a CNA and on a prior EM rotation. Seems every provider I worked with was old school and went with colchicine. Digging through charts, I saw a few other treatments - medrol dose pack and even one steroid injection. The only thing I haven't seen is the ONE thing they taught us to use in school - an NSAID, either ibuprofen, naproxen or classically indomethacin. I ask my providers and they tell me colchicine has always worked and they state it works better than NSAIDs, and that's why they use it. Should the NSAIDs be first line? Are these providers just sticking to their old habits? Is a medrol dose pack or steroid injection appropriate in any case (if so, which)? Thanks to all who chime in. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 7, 2013 Share Posted December 7, 2013 Current studies show any NSAID to be about as good as another. For me, if 5-6> occurrences in a year then needs preventive med and taper to guidelines goal. You can check UA if you wish but normal value doesn't exclude disease (preverbal don't ask question if you don't want to know answer). Modify diet with NSAID therapy. Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 7, 2013 Moderator Share Posted December 7, 2013 high dose NSAID 1rst Colchicine if able - but ONLY 1-2 doses - no more take it till diarrhea Steroids if needed - and for those with CRF that can't take NSAIDs (more people then you think) Sure stick a needle in it - get synovial fluid for analysis (to make Dx first time is most helpful) and put some steroids in - BUT remember the only true contraindication to joint injection is overlaying cellulitis.... and that is sometimes hard to distinguish.... So colchicine for just about everyone, then NSAID if okay, steroids if CRF DRINK lots of fluid if they will tolerate it (no hx of CHF) Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 7, 2013 Share Posted December 7, 2013 ventana, to find the CRF folks have to check/look. It has been my experience that they don't more often than not, especially if the lab doesn't figure the GFR for them since we all know it's now about "moving the meat". Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 8, 2013 Share Posted December 8, 2013 I agree with what everybody posted above (especially to not dose colchicine til you diarrhea). Only thing not mentioned is, don't use indomethacin. It has one of the high side effect profiles/rate of all the NSAIDs. Better to go with naproxen or ibuprofen. I am also a little hesistant to use high dose NSAIDs on a cardiac pt or a high-risk cardiac patient, although I am honestly not sure what the increased risk of a cardiac event is for a short-term course of NSAIDs. Oh, and make sure you switch out the thiazide or lasix for those patients with a hx of gout. Don't know why so few providers don't catch that... Link to comment Share on other sites More sharing options...
winterallsummer Posted December 8, 2013 Author Share Posted December 8, 2013 So what is 1st line? High dose naproxen? Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 9, 2013 Share Posted December 9, 2013 First line is high dose NSAIDs Naproxen has safest cardiac risk profile in the class. I don't think there's been any head-to-head between the NSAIDs done in acute gout Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 9, 2013 Share Posted December 9, 2013 ^^^ Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 9, 2013 Moderator Share Posted December 9, 2013 but naprosyn has one of the highest GI side effect of bleed...... I just let the patient pick unless there is strong evidence one way Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted December 9, 2013 Share Posted December 9, 2013 Like everything else, instead of worrying about what to give them long term how about having them modify their risk factors to start? I personally am not concerned so much about a GI bleed with a four to five day course of NSAID's unless there are extenuating circumstances. It always comes down to risk/reward. Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 9, 2013 Share Posted December 9, 2013 but naprosyn has one of the highest GI side effect of bleed...... I just let the patient pick unless there is strong evidence one way Good to know. I was unaware of that Link to comment Share on other sites More sharing options...
AREID Posted December 10, 2013 Share Posted December 10, 2013 NSAIDs first line. Naproxen has safest cardio profile. If worries about GI bleed combine w PPI, it's only going to be for a few days anyway. If you have one joint, steroid injection into joint works well. Iv never had to use colchicine and I take care of gouty flares a lot. Regarding the The diuretic, it's only hydrochlorothiazide that will increase uric acid levels and not lasix. Also, if they are on allopurinol, then the increase in uric acid is negligible. If you want to be nit picky, aspirin will also increase uric acid, but doubtful were gonna take people off those. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
AREID Posted December 10, 2013 Share Posted December 10, 2013 As far as oral steroids, those work well. You don't need to do a medrol dose pack. Like stated earlier it's only going to be for a few days. No need to taper when using steroids for this duration Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 10, 2013 Share Posted December 10, 2013 NSAIDs first line. Naproxen has safest cardio profile. If worries about GI bleed combine w PPI, it's only going to be for a few days anyway. If you have one joint, steroid injection into joint works well. Iv never had to use colchicine and I take care of gouty flares a lot. Regarding the The diuretic, it's only hydrochlorothiazide that will increase uric acid levels and not lasix. Also, if they are on allopurinol, then the increase in uric acid is negligible. If you want to be nit picky, aspirin will also increase uric acid, but doubtful were gonna take people off those. Sent from my iPhone using Tapatalk Not true, loop diuretics, especially furosemide will increase risk of gout (don't know how much, though) Link to comment Share on other sites More sharing options...
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