Chris Arnold’s November E-shift

1. Treatment of Acute Gout

Gout is a simple but fairly common cause of pain seen in emergency medicine. It can pose some issues with diagnosis, and treatment especially if the patient has renal disease.

Initial treatment of gout

1. Pain Control! This is a painful condition and NSAIDS, or Colchicine is not sufficient.
2. No benefit in urate lowering therapies (Allopurinol), but do not stop them if patient is already taking.
3. Aspirin is not used to treat acute gout because of the paradoxical effects of salicylates on serum urate, resulting from renal uric acid retention at low doses (<2 to 3 g/day) and from uricosuria at higher doses
4. NSAIDS are primary therapy. No difference between classes. Treatment duration is until symptoms resolve.
5. NSAIDS should not be used in patients with CAD, Chronic Renal Disease, Gastric Ulcers, NSAID intolerance, or patients with ongoing anticoagulation therapy.

Patients with contraindications to treatment with NSAIDs.

1. Colchicine is best therapy if symptoms have started within last 12 hours. The initial dose of 1.2 mg followed by 0.6 mg in one hour. Colchicine should then be continued 0.6 mg BID until resolution of symptoms.
2. Traditionally Colchicine was given as above but 0.6 mg tab was taken every hour until pain resolved or patient developed diarrhea and abdominal cramping (The patient only did this once). Furthermore, AGREE trial showed no benefit with this treatment regimen.
3. Finally Colchicine is contraindicated in patients with advanced renal or hepatic impairment because of risk of toxicity 2/2 decreased clearance.

Patients with Chronic Kidney Disease

1. Glucocorticoids are mainstay of treatment.   Intraarticular injections are acceptable if 2 or less joints are affected and if infections has been ruled out. In most patients with CKD oral glucocorticoids are treatment of choice in the Emergency Department. Prednisone 30-50mg q/day 7-10 days if initial flare, or 10-14 days if a recurrent attack.
2. Caution should be used with glucocorticoids in patients with diabetes as it can cause elevated blood sugar and if necessary patient should be educated of effects and need to monitor blood glucose and increase insulin requirements as needed.

 

2. Treatment and Prophylaxis for Spontaneous Bacterial Peritonitis

I recently had a patient with a GI bleed and a history of ascites. I had believed that I needed to treat them prophylactically for SBP, but could not remember the indications. When speaking to some of the other residents I realized it was a common gap in our knowledge.

Treatment for SBP is indicted if any of the following exist in a patient with ascites after fluid has been obtained and sent for culture.

1. Temperature > 37.8 C/100 F
2. Abdominal pain/tenderness
3. Change in Mental Status
4. Ascitic fluid PMN > 250

If SBP is highly suspected then treatment should begin immediately after fluid has been collected for culture, otherwise it can be postponed until PMN count is available. Treatment should be aimed at common G- bacteria such as E. Coli and Klebsiella. The recommend regimen is cefotaxime 2 grams IV q8 hours. Any third generation cephalosporin is a reasonable choice (since we done have cefotaxime), and if ceftriaxone is chosen the dose is 2 grams/day.

Prophylaxis is indicated in the following settings.

1. Cirrhosis and GI bleeding -> prophylaxis decreased mortality
2. History of SBP. 70% reoccurrence rate within one year.  
3. Cirrhosis and ascites fluid with low protein <1.5 g/dl and CKD defined as Creatinine >1.2, or BUN > 25, Sodium < 130, or advanced liver failure.

Treatment regimens for SBP prophylaxis vary by indication and I have simplified it here.

1. Ceftriaxone 1 gram/day for patients with GI bleeding
2. Patients with a history of SBP should have long term PPx with Bactrim DS.
3. The third group can be treated with daily Bactrim DS or Norfloxacin