coolbeans Posted June 9, 2013 Share Posted June 9, 2013 I have been working in the ER (south side Chicago) for about 5 months now and see a ton of patient with acute gout flare up. Most of the patients I see don't have any insurance or a primary care doctor. what is your preferred gout treatment? Some of the doctors I work with like using Indomethacin alone and some like to do a short course of Prednisone and Naproxen. Link to comment Share on other sites More sharing options...
bradtPA Posted June 9, 2013 Share Posted June 9, 2013 Not too fond of mixing steroids and NSAIDs, seen too many cases of renal failure from it, and indocin is harsh on the GI tract. A medrol dose pack is a cheap and effective tx though. Link to comment Share on other sites More sharing options...
rcdavis Posted June 9, 2013 Share Posted June 9, 2013 In Ed 2 colchrys 0.6mg each, po 10 mg decadron IM 10 mg Percocet po Crutches (this b*tch hurts!) Prednisone 20 mg #15 2 po qam x5d, 1 po qam x5d ( on $4 list) If insurance: lortabs 10 and colchrys #4 sig 1po bid x 2d and lortab 10 #10 If no insurance hydrocodone 5/325 sig 1-3q4-6h for pain Cold packs, elevate, time. No etoh. If had more than 3 flares in 12 months.. Would need referral to free clinic for Uris acid production/excretion determination, and appropriate maintainence treatment. Note: this only applies to folks with OBJECTIVE findings; warm, swollen joint(s), elevated Uris acid or sed rate, etc.. No merely someone who SAYS he has gout and SAYS He is having pain. If I were to decide to use NSAID ( any would work, indomethicine is sorta the standard).. Then baseline creatinine. Link to comment Share on other sites More sharing options...
Joelseff Posted June 10, 2013 Share Posted June 10, 2013 In Ed 2 colchrys 0.6mg each, po10 mg decadron IM 10 mg Percocet po Crutches (this b*tch hurts!) Prednisone 20 mg #15 2 po qam x5d, 1 po qam x5d ( on $4 list) If insurance: lortabs 10 and colchrys #4 sig 1po bid x 2d and lortab 10 #10 If no insurance hydrocodone 5/325 sig 1-3q4-6h for pain Cold packs, elevate, time. No etoh. If had more than 3 flares in 12 months.. Would need referral to free clinic for Uris acid production/excretion determination, and appropriate maintainence treatment. Note: this only applies to folks with OBJECTIVE findings; warm, swollen joint(s), elevated Uris acid or sed rate, etc.. No merely someone who SAY If I were to decide to use NSAID ( any would work, indomethicine is sorta the standard).. Then baseline creatinine. I agree with the above and colcrys can also be used as ppx after the flare. I measure Urate levels but not use it as a hard and fast rule to determine treat no treat. I have seen Gouty flares with urates in the 4's and asymptomatic patients in the 8's so YMMV. I use it as a baseline for each pt and pretty much treat based on symptoms and exam/presentation. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted June 10, 2013 Moderator Share Posted June 10, 2013 I never measure uric acid levels, unless ortho requests them in a consult. If the joint is warm and red enough to tap it to rule out septic arthritis, then I get crystal studies along with the studies to rule out the major badness. If it's just clinical gestalt and I don't tap/draw labs, then at the very least NSAIDs/steroids, and maybe colchicine if suspicion is higher. Link to comment Share on other sites More sharing options...
bradtPA Posted June 10, 2013 Share Posted June 10, 2013 I agree with the above and colcrys can also be used as ppx after the flare. I measure Urate levels but not use it as a hard and fast rule to determine treat no treat. I have seen Gouty flares with urates in the 4's and asymptomatic patients in the 8's so YMMV. I use it as a baseline for each pt and pretty much treat based on symptoms and exam/presentation. Colcrys is great, just pricey, and probably out of reach for uninsured inner city patients in Chicago. In a perfect world I use it bid, then add either allopurinol or Uloric two weeks after the attack is over.... Link to comment Share on other sites More sharing options...
medic25 Posted June 10, 2013 Share Posted June 10, 2013 I never measure uric acid levels, unless ortho requests them in a consult. If the joint is warm and red enough to tap it to rule out septic arthritis, then I get crystal studies along with the studies to rule out the major badness. If it's just clinical gestalt and I don't tap/draw labs, then at the very least NSAIDs/steroids, and maybe colchicine if suspicion is higher. Agreed with above. The uric acid level doesn't correlate with an acute flare, so I don't bother getting it if it won't change my management. First-time presentation or atypical presentation gets a joint tap; if they can tell me this feels like their usual gout flare then it's usually indomethacin and colchicine, with steroids for those who can't tolerate NSAID's. Link to comment Share on other sites More sharing options...
coolbeans Posted June 11, 2013 Author Share Posted June 11, 2013 We actually have colchicine in the outpatient formulary for $4!!! I usually never get uric acid level, unless it is their first presentation. I usually prescribe indomethacine and colchicine but have seen different supervising physician prescribing all sorts of things including allopurinol and prednisone. If you do write for indomethacine, do you taper it down?? Thank you so much for everyone's reply! I really appreciate it! Link to comment Share on other sites More sharing options...
rcdavis Posted June 11, 2013 Share Posted June 11, 2013 We actually have colchicine in the outpatient formulary for $4!!! I usually never get uric acid level, unless it is their first presentation. I usually prescribe indomethacine and colchicine but have seen different supervising physician prescribing all sorts of things including allopurinol and prednisone. If you do write for indomethacine, do you taper it down?? Thank you so much for everyone's reply! I really appreciate it! No need to taper indomethicin, ever. Probably no need to taper steroids for treatments less than 2 weeks duration Colchicine?? Available??? Word is FDA. Asked manufacturer to conduct proof of efficacy studies ( stage 1-3), to prove that it ( a medicine that Hippocrates used) .. Works.. Used to be 6 bucks for 100 tablets. Now, thanks to FDA, it is now z100 bucks for 6 tablets. If you have enough, I'll buy all you have. Link to comment Share on other sites More sharing options...
coolbeans Posted June 14, 2013 Author Share Posted June 14, 2013 No need to taper indomethicin, ever.Probably no need to taper steroids for treatments less than 2 weeks duration Colchicine?? Available??? Word is FDA. Asked manufacturer to conduct proof of efficacy studies ( stage 1-3), to prove that it ( a medicine that Hippocrates used) .. Works.. Used to be 6 bucks for 100 tablets. Now, thanks to FDA, it is now z100 bucks for 6 tablets. If you have enough, I'll buy all you have I work for the county hospital and have colchicine on the outpatient formulary for $4. Well, all the medications have $4 copay. Link to comment Share on other sites More sharing options...
Guest JMPA Posted June 15, 2013 Share Posted June 15, 2013 i treat everything with surgery, when in doubt cut it out Link to comment Share on other sites More sharing options...
Guest Paula Posted June 15, 2013 Share Posted June 15, 2013 i treat everything with surgery, when in doubt cut it out You are on a roll today and entertaining us all. Link to comment Share on other sites More sharing options...
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