NURS 504 Week 5 Disease State PowerPoint Presentation on Gout Example

Gout Is a Treat-to-Target Disease: A Pharmacology Briefing for Nursing Colleagues

Slide 1: Gout Is a Treat-to-Target Disease

• Urate crystals, not just painful joints
• Flares need treatment; the disease needs a target
• Today: crystals, flares, urate-lowering therapy, nursing roles

Speaker notes: Thank you for coming. In the next twenty minutes I want to change how we think about one common disease. Most of us meet gout during a flare, a hot, swollen big toe in the emergency department or on the unit. We treat the pain and the patient goes home. The message of this session is that the flare is only the visible part of a chronic disease caused by urate crystals, and that the disease has a target we can measure and reach.

Slide 2: A Patient We All Know

• Second flare in a year, treated with an anti-inflammatory
• No urate level checked, no long-term plan
• Third flare four months later

Speaker notes: Picture a composite patient, a 61-year-old with high blood pressure on a thiazide diuretic, who comes in with a second flare in a year. The flare is treated well, but no one checks the serum urate or starts a long-term plan, and the patient returns four months later with a third. This pattern is common, and it is preventable.

Slide 3: How Crystals Cause Disease

• Urate above about 6.8 mg/dL can crystallize in joints
• Crystals trigger intense inflammation
• Repeated flares lead to tophi and joint damage

Speaker notes: Uric acid is the end product of purine breakdown. When serum urate rises above its saturation point of about 6.8 milligrams per deciliter, monosodium urate crystals can form in and around joints. Crystals activate the innate immune system and cause the sudden, severe inflammation of a flare. Over years, crystal deposits called tophi can form and damage joints and bone (Burchum & Rosenthal, 2019). Lowering urate below the saturation point is the only way to dissolve the crystals that cause every future flare.

Slide 4: Recognizing a Flare

• Sudden pain, swelling, redness, often at night
• First joint at the base of the big toe is classic
• Joint fluid crystals confirm the diagnosis

Speaker notes: A typical flare starts suddenly, often overnight, with severe pain, swelling, warmth and redness, most often in the first metatarsophalangeal joint, though ankles, knees and wrists are also common. Identifying crystals in joint fluid confirms the diagnosis. Serum urate can be normal during a flare, so a normal level does not rule gout out.

Slide 5: Treating the Flare

• Low-dose colchicine, an NSAID or a corticosteroid
• Choose by kidney function, other conditions and drug interactions
• Start early: the first 24 hours matter

Speaker notes: The 2020 American College of Rheumatology guideline recommends low-dose colchicine, a nonsteroidal anti-inflammatory drug or a corticosteroid as first-line options for a flare, chosen according to the patient's other conditions (FitzGerald et al., 2020). Colchicine works best when started within a day of symptoms; the low-dose regimen of 1.2 mg followed by 0.6 mg an hour later is as effective as older high-dose regimens with fewer side effects. NSAIDs are avoided in kidney disease, heart failure and peptic ulcer disease, and corticosteroids are useful when those conditions are present.

Slide 6: Colchicine Cautions

• Diarrhea and nausea are common
• Dangerous with strong CYP3A4 or P-glycoprotein inhibitors
• Reduce or avoid in kidney or liver impairment

Speaker notes: Colchicine has a narrow therapeutic range. Its levels rise sharply with drugs such as clarithromycin, some antifungals and some calcium channel blockers that inhibit CYP3A4 or P-glycoprotein, and serious toxicity has occurred with these combinations (Wells et al., 2018). Always check the medication list before giving it.

Slide 7: Who Needs Urate-Lowering Therapy

• Tophi, frequent flares, or joint damage on imaging: start
• After a first flare: usually discuss, start for some
• Goal: serum urate below 6 mg/dL

Speaker notes: The guideline strongly recommends urate-lowering therapy for patients with tophi, two or more flares a year or radiographic damage from gout, and it gives conditional guidance for others, such as starting after a first flare when kidney disease, a very high urate or kidney stones are present (FitzGerald et al., 2020). Our patient, with two flares in a year, meets the threshold.

Slide 8: Allopurinol First, Started Low

• First-line for most patients, including kidney disease
• Start at 100 mg daily or less, less in advanced kidney disease
• Raise every few weeks until urate is below 6

Speaker notes: Allopurinol, a xanthine oxidase inhibitor, reduces uric acid production. The guideline recommends it as the preferred first-line agent, starting at 100 milligrams a day or less, and lower in stage 4 or worse kidney disease, then increasing gradually until the urate target is reached (FitzGerald et al., 2020). Starting low reduces both early flares and the risk of severe hypersensitivity. Many patients need 300 milligrams or more, which is why doses must be titrated rather than left at the starting dose.

Slide 9: A Genetic Test Before Allopurinol

• HLA-B*5801 raises the risk of severe hypersensitivity
• Test patients of Southeast Asian descent and African American patients
• Severe reactions: rash, fever, organ injury

Speaker notes: Allopurinol hypersensitivity syndrome is rare but can be fatal. Its risk is much higher in people carrying the HLA-B*5801 allele, which is more common in some Asian populations and in African American patients, and the guideline recommends testing these patients before starting allopurinol (FitzGerald et al., 2020). Patients should stop the drug and seek care for any rash.

Slide 10: Preventing Flares While Urate Falls

• Falling urate can trigger flares at first
• Prophylaxis for three to six months: colchicine, NSAID or prednisone
• Continue urate-lowering therapy through any flare

Speaker notes: When urate levels drop, crystals shift and can trigger flares, which discourage patients who were told the new pill would prevent them. The guideline recommends anti-inflammatory prophylaxis for three to six months after starting urate-lowering therapy, and it advises continuing urate-lowering therapy during a flare rather than stopping it. A nurse who warns patients about this ahead of time can prevent many of them from quitting.

Slide 11: Febuxostat and Its Two Safety Trials

• CARES: more cardiovascular deaths than allopurinol
• FAST: no increase in cardiovascular events
• Reserved for patients who cannot use allopurinol

Speaker notes: Febuxostat, another xanthine oxidase inhibitor, lowers urate effectively, but its safety has been debated. In the CARES trial of patients with gout and cardiovascular disease, febuxostat was noninferior to allopurinol for the combined cardiovascular end point, but cardiovascular and all-cause deaths were higher with febuxostat (White et al., 2018). The later FAST trial in Europe found febuxostat noninferior to allopurinol for cardiovascular events without an increase in deaths (Mackenzie et al., 2020). Allopurinol remains first-line, with febuxostat an option when allopurinol cannot be used, used with caution in patients with cardiovascular disease.

Slide 12: Medicines That Raise Urate

• Thiazide and loop diuretics raise urate
• Losartan lowers urate and can replace a thiazide for blood pressure
• Low-dose aspirin can raise urate but continue if needed

Speaker notes: For our patient on a thiazide, the guideline conditionally recommends switching hydrochlorothiazide to another blood pressure drug when feasible, and it prefers losartan, which has a modest urate-lowering effect (FitzGerald et al., 2020). Low-dose aspirin for cardiovascular protection should continue.

Slide 13: Lifestyle Matters, but Rarely Alone

• Limit alcohol, especially beer, and sugary drinks
• Weight loss for patients with obesity
• Diet helps, but most patients still need medication

Speaker notes: Limiting alcohol, sugar-sweetened beverages and high-purine foods, and losing weight when appropriate, can lower urate modestly. Patients sometimes believe diet alone should be enough, and it is kind to tell them honestly that most people with recurrent gout need medication as well.

Slide 14: What Nurses Can Do

• Check that a urate level and a long-term plan follow every flare
• Teach: flares may rise at first, keep taking the pill
• Track urate every few weeks until below 6, then periodically

Speaker notes: Nurses can close the gap shown by our composite patient. After any flare, ask whether a urate level and a long-term plan are in place. Teach patients that early flares are expected and are not a reason to stop. Make sure urate is rechecked during titration and that the dose rises until the target is met. That is the whole message of today: treat the flare, and treat the disease to its target.

Slide 15: References

• FitzGerald et al. (2020), 2020 American College of Rheumatology guideline.
• White et al. (2018), CARES trial.
• Mackenzie et al. (2020), FAST trial.
• Burchum and Rosenthal (2019); Wells et al. (2018).

References

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

FitzGerald, J. D., Dalbeth, N., Mikuls, T., Brignardello-Petersen, R., Guyatt, G., Abeles, A. M., Gelber, A. C., Harrold, L. R., Khanna, D., King, C., Levy, G., Libbey, C., Mount, D., Pillinger, M. H., Rosenthal, A., Singh, J. A., Sims, J. E., Smith, B. J., Wenger, N. S., . . . Neogi, T. (2020). 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care & Research, 72(6), 744-760. https://doi.org/10.1002/acr.24180

Mackenzie, I. S., Ford, I., Nuki, G., Hallas, J., Hawkey, C. J., Webster, J., Ralston, S. H., Walters, M., Robertson, M., De Caterina, R., Findlay, E., Perez-Ruiz, F., McMurray, J. J. V., MacDonald, T. M., Aziz, J., Dobson, G., Doney, A., Flynn, R., Furnace, J., . . . Waller, T. (2020). Long-term cardiovascular safety of febuxostat compared with allopurinol in patients with gout (FAST): A multicentre, prospective, randomised, open-label, non-inferiority trial. The Lancet, 396(10264), 1745-1757. https://doi.org/10.1016/S0140-6736(20)32234-0

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.

White, W. B., Saag, K. G., Becker, M. A., Borer, J. S., Gorelick, P. B., Whelton, A., Hunt, B., Castillo, M., & Gunawardhana, L. (2018). Cardiovascular safety of febuxostat or allopurinol in patients with gout. The New England Journal of Medicine, 378(13), 1200-1210. https://doi.org/10.1056/NEJMoa1710895