Monday, May 16, 2022

Gout In The Emergency Department

Diabetes Polyarticular Gout Prior Opioid Use Tied To Increased Risk For Opioid Prescription At Discharge

Take a Stand on Gout: Gout Patient Care in the ER

MONDAY, July 15, 2019 — More than one-fourth of patients with acute gout discharged from the emergency department receive an opioid prescription, according to a study published online July 2 in Arthritis Care & Research.

Deepan S. Dalal, M.D., M.P.H., from Brown University in Providence, Rhode Island, and colleagues used electronic health records from Lifespan Healthcare facilities to identify adult patients discharged from the emergency department or hospital with a primary diagnosis of gout between March 30, 2015, and Sept. 30, 2017.

The researchers found that of 456 patients identified, 28.3 percent received an opioid prescription at discharge. Approximately 80 percent were new prescriptions. The average prescription dose was 37.9 mg of morphine equivalent for a median of eight days . More than one-quarter of patients received an opioid prescription for 14 days, which is longer than the natural course of a typical gout attack. Patients with polyarticular gout attack and diabetes, as well as those using opioids prior to admission, had higher odds of receiving an opioid prescription at discharge.

“This study highlights an opportunity to curb the opioid epidemic among gout patients,” the authors write.

Quality Of Gout Care In The Emergency Departments: A Multicentre Study

BACKGROUND:

To report on prevalence of gout flare in emergency departments and to report the quality of gout care in emergency departments and causes of admission at emergency departments.

METHODS:

A retrospective chart review of visits that had a primary diagnosis in gout by the International Classification of Diseases, the tenth revision, at emergency departments from 6 universities in Thailand over a 5year period from 1 January 2012 to 31 December 2016.

RESULTS:

Six hundred thirty-two visits were included to the study. Prevalence of gout flare in emergency departments was 0.04. Only 29.3% of the visits had arthrocentesis. 628/632 and 519/585 of the visits were prescribed medications in emergency departments and had home medications, respectively. Although all visits that were prescribed colchicine in emergency departments received adequate doses of colchicine, it was also found that more than 2.4mg/day of colchicine was prescribed for home medications. In addition, 183/343 of the visits with normal renal function were prescribed non-steroidal anti-inflammatory drugs . However, prescribed NSAIDs in abnormal renal function was also found. The interruption of dosing, including increase, decrease, addition or discontinuance of urate lowing therapy in a gout flare period was 42/632 . The most common cause of admission was acute gouty arthritis .

Carenow Urgent Care Can Help Provide Relief

If you have been diagnosed with gout and begin to experience a hot, red, swollen joint, its essential that you seek medical care as this may be a result of an infection or loss of joint cartilage.

You should also see a doctor if you begin suffering from multiple attacks of arthritis. This may mean you need daily medication to prevent future flare-ups.

If you are suffering from gout and arthritis caused by gout, visit CareNow® for a uric acid test and to learn how you can minimize symptoms.

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Opioids Commonly Prescribed For Gout Attacks

NEW YORK Nearly three in 10 patients seeking care at the emergency department for acute gout will be discharged with a prescription for opioids, new research shows.

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Our study suggests a high use of prescription opioid in patients discharged from the ED with a diagnosis of gout, a condition that can be managed effectively with other medications, Deepan S. Dalal, MD, of Brown University Warren Alpert School of Medicine, Providence, and colleagues write.

Steroids, non-steroidal anti-inflammatory drugs and colchicine can reduce pain and inflammation from gout attacks, the authors note in Arthritis Care and Research, online July 3.1

Despite the efficacy of conventional agents, empirical evidence suggests common use of opioid analgesics in gout management, they add.

The authors looked at Lifespan Healthcare Systems data on 456 patients discharged from the ED or hospital after treatment of acute gout between 2015 and 2017. At discharge, 28.3% were prescribed an opioid, 79% had not been on opioid medications previously.

The average dose was 37.9 mg of morphine equivalent for a median eight days.

Opioid prescription type was available for 119 patients, including 81% prescribed oxycodone or combinations of oxycodone, 8% prescribed hydrocodone and 9% prescribed tramadol.

How Do I Deal With Gout

(PDF) SAT0381 Diagnosis and Treatment of Acute Gouty ...

Gout is a type of arthritis caused by the buildup of uric acid in your bloodstream, resulting in red, hot, stiff, and swollen joints. Although not everyone with high uric acid levels develops gout, in some patients the formation of uric acid crystals in the fluid that surrounds their joints causes this often agonizing condition, characterized by joint soreness and inflammation.

Acute gout is rather painful and tends to affect one joint in particular. Chronic gout, on the other hand, is marked by recurring instances of discomfort and inflammation that usually affect multiple joints in your body.

The presence of excessive uric acid in your system may occur because your body produces too much of it or because it has difficulty eliminating it properly. In addition, uric acid levels may be elevated if your diet includes too many purines, which are organic compounds that are found in almost every food product and metabolize into uric acid. Foods that are particularly high in purines include:

  • dried beans
  • scallops
  • yeast

Your risk of gout increases if you are male, if you consume alcohol, and if it is part of your familys medical history. In addition, post-menopausal women are susceptible to the condition, as are those suffering from obesity, diabetes, kidney disease, anemia, and leukemia. Certain diuretic medications may also increase uric acid levels in your blood.

Among the symptoms of acute gout are:

Medication options for gout include:

Recommended Reading: Cherry Juice For Gout Mayo Clinic

Patterns Of Health Care Utilization Of Gout Patients In Hawaii

  • Roles Data curation, Formal analysis, Investigation, Methodology, Writing original draft, Writing review & editing

    Affiliation Saint Louis University, St. Louis, Missouri, United States of America

  • Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Writing original draft, Writing review & editing

    Affiliation Hawaii Pacific Health Research Institute, Honolulu, HI, United States of America

  • Roles Formal analysis, Investigation, Methodology, Validation, Writing original draft, Writing review & editing

    Affiliation Department of Complementary and Integrative Medicine, University of Hawaii, Honolulu, HI, United Sttaes of America

  • Roles Conceptualization, Formal analysis, Investigation, Methodology, Software, Supervision, Validation, Writing original draft, Writing review & editing

    Affiliation Department of Complementary and Integrative Medicine, University of Hawaii, Honolulu, HI, United Sttaes of America

Evaluating The Treatment Of Acute Gout Flares In The Emergency Department

    With the rise in number of opioid addictions, alternative long-term care and acute flare management for gout should be further addressed, according to a letter to the editor published in Arthritis Care & Research.1

    Researchers previously reported on the diagnosis and treatment of acute gout flares in a 541 consecutive emergency department visits over a 7-year period.2 They indicated that among patients who visited the ED for an acute gout flare, 35% received an opioid and 52% received a prescription for an opioid. According to another study, opioids were prescribed more than 50% of the time in the ED for acute gout flares3 however, the researchers pointed out that the use of analgesia alone does not treat gouty inflammation.

    Researchers of this study noted that treatment programs need to consider that gout is a long-term, chronic disease that requires continuous management the possibility that acute flare-ups can occur must be considered. Research is necessary to address if the use of opioids for acute gout flares in the ED is warranted as well as to establish evidence-based guidelines for treating gout flares.

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    Lesley Jackson Md: Gout Flare Electronic Medical Record Alert

    Poster Session B8:30 10:30 a.m. ET Sunday, Nov. 7All ACR Convergence 2021 poster presentations are available on demand to registered meeting participants through March 11, 2022.

    What is your poster about?The objective of our study was to refine a multicriteria electronic medical record alert to identify patients with a gout flare during an emergency department visit. The gout flare alert used EMR data from the chief medical complaint or problem list entered by ED nursing staff during patient triage. It could be triggered by one or more criteria, which were based on a combination of the presence of the key term gout listed in the chief complaint or problem list in conjunction with a musculoskeletal complaint. Our alert had reasonable sensitivity of 75% and specificity of 82%. This approach may be a useful strategy to identify and potentially recruit participants with acute gout flare for studies.

    What are you working on next related to this research?We recently began enrollment for a randomized clinical trial of a behavioral intervention in people with acute gout flare who present to the ED. We are utilizing this alert to identify potential participants for recruitment in this study.

    Home Care For A Gout Flare

    FDA greenlighting new drug for gout

    If your doctor has diagnosed you with gout and given you medicine for a flare-up, take the medicine as directed when you know youâre having one. In most cases, that will probably be as soon as the first signs begin.

    Your doctor may prescribe nonsteroidal anti-inflammatory drugs such as celecoxib, indomethacin, meloxicam, or sulindac or suggest you take over-the-counter NSAIDs, like naproxen or ibuprofen. Depending on your medical history, your doctor may prescribe steroids or other medicines to reduce inflammation, such as colchicine .

    In some cases, you already may be taking medicine like colchicine to prevent gout flare-ups. Your doctor may have also suggested:

    If you canât take allopurinol or it is not effective, your doctor may prescribe . It should be used with caution, however, because it has been linked to increased risk of death from heart disease and from other causes.

    Just because you have a flare doesn’t mean these medicines aren’t working. In the first few months that you take them, you may have an attack as your body adjusts to the drug. Your doctor will likely have given you something to take if this happens, too.

    If youâve been taking preventive gout medicine for a long time and youâre having flares for the first time in a while, call your doctor. They may talk to you about changing your dosage or your medicine.

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    Gout Emergency Department Visits Up

    Gout, a common form of inflammatory arthritis, results from both genetic and environmental factors. Physicians must actively manage gout patients to prevent elevated blood levels of uric acid from forming the thin, rod-like monosodium urate crystals that deposit in the joints. These deposits lead to severe pain, stiffness and joint damage. For physicians, patient management includes considering the socioeconomic, dietary and medical factors that influence uric acid levels and/or facilitate MSU crystal formation in the patient. Such risk factors include hyperuricemia, medications, comorbidities and lead exposure.

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    Globally, experts estimate the prevalence of gout to be between 0.1% and 10%, with an incidence of between 0.3 to 6 cases per 1,000 person-years.1 Although the prevalence and incidence of gout vary by region, both are increasing in many developed countries.

    Arthritis In The Emergency Department Research Study

    Emergency Department Use by Patients with Inflammatory Arthritis Conditions: Health System Impact and Solutions for Ensuring Appropriate Care Access

    Invitation to Participate in a Survey

    ADULT PATIENTS:Our research team is seeking participants with inflammatory arthritis conditions who have been a patient in the emergency department recently to answer an online survey about their visit there. In this survey, we will ask you about your decision to go to the emergency department, what you did for your symptoms before going there, and what happened while you were there. The survey is expected to take 15 minutes to complete. If you are interested in participating, please click on the following link to take you to the consent form and the survey.

    PARENTS OF PEDIATRIC PATIENTS:Our research team is seeking parents with a child with Juvenile Idiopathic Arthritis who has been a patient in the emergency department recently to answer an online survey about their visit there. In this survey, we will ask you about your decision to go to the emergency department, what was done at home for symptoms before going there, and what happened while you and your child were there. The survey is expected to take 15 minutes to complete. If you are interested in participating, please click on the following link to take you to the consent form and the survey.

    Parents of Patients:

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    Pain Relief Without Medicine

    Use cold. If your pain isn’t too bad, try cold packs or compresses on the joint to lower inflammation and soothe the ache. Wrap ice in a thin towel and apply it to the joint for up to 20 minutes several times a day. Do not apply ice to your hands or feet if you have nerve problems from diabetes or other causes.

    Rest the joint. It’s a good idea to rest it until the pain eases up. You probably won’t want to move it much anyway. If you can, raise the joint on a pillow or other soft object.

    Drink water. When your body doesnât have enough water, your uric acid levels rise even higher. Stay hydrated to help keep those levels normal.

    Watch what you eat and drink. Foods that are high in substances called purines, such as some seafood, organ meats like liver, and fatty foods, can raise the uric acid in your blood even more. So can fructose-sweetened drinks and alcohol — especially beer.

    Points And Pearls Excerpt

    Emergency Gout Relief  OsteoEze
    • There are 6 broad categories of arthritis : infectious, degenerative, autoimmune, crystal deposition-related, reactive, and traumatic.
    • Although joint pain has traditionally been thought of as either monoarticular or polyarticular, do not eliminate a disease based solely on these binary classifications, as some can present with single or multiple joints.
    • The number of affected joints, their locations, and symmetry of distribution can help identify the cause of the joint pain.
    • There are no disease-modifying treatments for osteoarthritis symptom relief is the main focus. Intra-articular injections of corticosteroids or hyaluronic acid can be performed in the ED.
    • Pregnant and menstruating women and patients with a complement deficiency are most at risk for gonococcal arthritis. Antibiotic recommendations for gonococcal arthritis were updated by the CDC in 2020.
    • Monoarticular vs polyarticular presentation
    • Infectious, degenerative, autoimmune, crystal deposition, reactive, traumatic
    • Bimodal incidence
    • Risks
  • Gonococcal
  • Viral (Zika, chikungunya, human parvovirus B19, hepatitis_
  • Degenerative osteoarthritis
  • History
  • Physical examination
  • Labs: do we need them?
  • Imaging
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    Pharmacological Treatments For Gout Flares In Hospitalized Patients

    Two RCTs compared NSAIDs and corticosteroids in patients presenting to EDs with gout flares . In both studies, participants were randomized to receive prednisolone 30mg daily for 5days or indomethacin 50mg three times daily for 2days followed by indomethacin 25mg daily for 3days. All participants received concomitant paracetamol 1g, up to 4 times daily as required.

    In the larger of the two studies, 416 participants from four EDs were recruited and randomized, of whom 376 participants completed the study . In intention-to-treat and per-protocol analyses, reductions in pain scores were similar between the prednisolone and indomethacin arms, both in ED and by day 14. No serious adverse events occurred with either intervention. Minor adverse events were more frequent with indomethacin than prednisolone during the ED stays but not subsequently. Length of stay in ED did not differ between the study arms . There were no significant differences in the proportion of participants returning to ED within 14days.

    When To Get Help For A Gout Flare

    It’s always a good idea to let your doctor know that you are having a flare. Sometimes, you may need to follow up to make sure your treatment plan is working or if your symptoms don’t improve. Call your doctor if:

    This is your first flare-up. There are several other conditions, such as a joint infection, that have some of the same symptoms as gout attacks.

    You have a highfever and chills. Gout attack symptoms may include a mild fever, but a higher temperature may be a sign of an infection.

    Your symptoms don’t get any better after 48 hours or don’t end after about a week. If you don’t start to feel somewhat better after a few days, call your doctor. They may suggest a different treatment. Most gout attacks will go away by themselves in several weeks, even without treatment.

    Show Sources

    Rebecca Manno, MD, MHS, assistant professor of medicine, division of rheumatology, Johns Hopkins University School of Medicine.

    Robert T. Keenan, MD, MPH, assistant professor of medicine, division of rheumatology and immunology, Duke University School of Medicine.

    Scott Zashin, MD, clinical professor of medicine, University of Texas Southwestern Medical School attending physician, Presbyterian Hospital.

    Lan Chen, MD, PhD, attending rheumatologist, Penn Presbyterian Medical Center.

    Gout and Pseudogout Treatment & Management: “Treatment.”

    Johns Hopkins Arthritis Center: “Gout — Treatments for Gout.”

    Merck Manual: “Gout.”

    Recommended Reading: Almonds And Gout

    Ult For The Prevention Of Gout Flares In Hospitalized Patients

    The benefits of ULT on hospitalizations and ED attendances have been evaluated in retrospective analyses. In a single-centre study of US veterans attending ED for gout flares, use of ULT was associated with fewer ED visits for gout flares , relative to those with no use of ULT .

    In a casecontrol study, patients hospitalized for gout at least twice in the preceding year were less likely to have received allopurinol than age-, sex- and ethnicity-matched controls with gout but without hospital admissions . The median allopurinol dosages were lower in patients with recurrent admissions than in the comparator group , and hospitalized patients were less likely to have been prescribed colchicine prophylaxis . Relative to those without recurrent admissions, patients with recurrent admissions had more comorbidities , more comorbid heart disease , higher rates of erosive gout and more tophaceous disease . Patients with recurrent hospital admissions for gout were also more likely to have been admitted for other conditions in the preceding year .

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