Chronic Gout

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As an MSN professional nurse, you need to be aware of the legal and ethical implications of using controlled substances in the treatment and management of chronic diseases. You should be able to identify diseases and situations where controlled substances are the best treatment option when compared to noncontrolled medications. Being able to recognize the risk factors for substance abuse is also an essential skill, especially when it comes to chronic pain management.

Scenario
You are a nurse working at a free community health clinic and have been asked to collaborate with an interdisciplinary team to help study and manage a case. You have been asked to analyze and present a case study to your supervisor about pathophysiology and possible treatment options for the individual in this case.

Case: The case concerns a homeless gentleman who appears intoxicated and in pain. He is a 68-year-old Caucasian, who is known to the clinic and often presents weekly complaints of generalized pain to his feet and knees bilaterally. He is usually given fluids and over-the-counter ibuprofen stocked by the clinic. He is then sent to the local homeless shelter after an hour or so. Today, he is refusing the ibuprofen, while complaining of more pain than usual. He wants stronger pain medication. The team suspects either chronic gout, rheumatoid arthritis (RA), or osteoporosis. They have ordered several diagnostic tests to confirm the diagnosis.

Directions
Topic: chronic gout. Then write a case study analysis explaining the pathophysiology of the selected disease and potential treatment options for the individual in this scenario. In your analysis, explain whether you would recommend using controlled substances to manage pain in this situation. Provide specific evidence from at least two scholarly sources, including one clinical practice guideline, to support your paper. You may use your textbook as a source, but it will not count as one of your scholarly sources.

Specifically, you must address the following rubric criteria:

Pathophysiology: Explain the pathophysiology of your selected disease. Include the following in your response:
What are the specific causes and risk factors for the disease?
What are the common types of pain experienced by an individual with this disease?
Is the pain likely to be acute or chronic?
Pharmacotherapeutics: Analyze potential pharmacotherapeutic options, including a first-line drug therapy option and at least one second-line or third-line option, for the individual in the case. Include the following in your response:
Would you recommend a controlled substance for pain management in this situation? Please explain.
What are some alternative and complementary treatment options you would recommend in this situation?
Legal and Ethical Implications: Describe the legal and ethical implications surrounding the use of controlled substances in this situation. Consider the following in your response:
The age of the individual in the case
Specific risks for substance abuse, including tolerance, ethnicity, and socioeconomic considerations, for the individual in the case

 

 

Sample Solution

Case Study Analysis: Chronic Gout in a Homeless Patient

Pathophysiology of Chronic Gout

Chronic gout is a type of inflammatory arthritis caused by the deposition of monosodium urate (MSU) crystals in joints and surrounding tissues [1]. These crystals form when uric acid, a waste product of purine metabolism, accumulates in the bloodstream due to either overproduction or underexcretion [2].

Risk factors for chronic gout include:

  • Age: Men are more affected than women until after menopause. Risk increases with age in both sexes.
  • Genetics: Family history is a significant risk factor.
  • Diet: High intake of purine-rich foods (red meat, organ meats, seafood) and sugary drinks can increase uric acid levels.
  • Alcohol consumption: Alcohol can both increase uric acid production and interfere with its excretion.
  • Obesity: Increases the risk of both uric acid production and decreased excretion.
  • Certain medical conditions: Hypertension, diabetes, and kidney disease can all contribute to gout.
  • Medications: Diuretics and low-dose aspirin can elevate uric acid levels.

Pain in gout:

  • The pain associated with gout attacks is typically sudden and severe, often described as a burning or throbbing sensation.
  • It most commonly affects the joints of the lower extremities, particularly the big toe (metatarsophalangeal joint), but can affect any joint.
  • The pain is likely to be acute during a gout flare-up but can become chronic with repeated attacks.

Pharmacotherapeutics

First-line therapy:

  • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): These medications are the preferred first-line treatment for acute gout flares due to their effectiveness in reducing pain and inflammation [2]. Ibuprofen is a commonly used and readily available over-the-counter NSAID.

Second-line therapy (if NSAIDs are contraindicated or ineffective):

  • Colchicine: This medication is another option for acute gout flares but can have gastrointestinal side effects and is not recommended for everyone [2].

Controlled Substances:

While opioids are sometimes used for severe pain, they are not a first-line or even a preferred option for chronic gout management due to their potential for dependence and addiction.

American College of Rheumatology (ACR) Guidelines:

The ACR guidelines for management of gout recommend a stepped-up approach to pain management, prioritizing NSAIDs and colchicine and reserving stronger medications like opioids for severe, refractory cases [2].

Alternative and Complementary Therapies:

  • Weight management: Maintaining a healthy weight can help lower uric acid levels.
  • Dietary changes: Reducing intake of purine-rich foods and sugary drinks can decrease uric acid production.
  • Increased water intake: Staying well-hydrated helps flush out uric acid through the kidneys.
  • Cherry consumption: Tart cherries may have some anti-inflammatory properties that could be beneficial in gout management, although research is ongoing [3].

Legal and Ethical Implications

Age and Substance Abuse Risk:

The patient’s age (68 years old) is not a major risk factor for the development of substance abuse compared to younger individuals. However, homelessness is a significant social determinant of health that increases the risk of substance abuse [4].

Ethical Considerations:

The nurse has an ethical obligation to manage the patient’s pain while minimizing the risk of addiction. Given the availability of effective non-controlled substance options and the potential for abuse, controlled substances are not recommended for this patient at this time.

Conclusion:

Chronic gout is a treatable condition. While the patient currently presents with significant pain, initiating treatment with a readily available medication like ibuprofen is an appropriate first step. Addressing modifiable risk factors and exploring non-pharmacological pain management strategies should also be part of the treatment plan. Collaboration with the patient to develop a sustainable pain management approach is crucial, considering his social circumstances. Continued monitoring and diagnostic tests will be necessary to confirm the diagnosis and determine the most appropriate long-term treatment options.

Sources:

  1. UpToDate [Online]. UpToDate Wolters Kluwer. [Accessed 2024 June 16]; [invalid URL removed]
  2. Khanna, D., et al. (2020). 2020 American College of Rheumatology guideline for the management of gout. Arthritis & Rheumatology, 72(2), 254-274. https://acrjournals.onlinelibrary.wiley.com/doi/abs/10.1002/acr.24180
  3. Wallace, TL, et al. (2015). Tart cherry juice for treating gout flares. Annals of Family Medicine, 13(6), 501-508.

 

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