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From Science to Practice - Gout Case Study in Primary Care


From Science to Practice - Gout Case Study in Primary Care

Topic: Rheumatology
Relevant Terms: Gout, tophi, serum uric acid
Primary Audience: Primary Care Physicians, Internal Medicine, General Practice, Nurses, Physician Assistants
Launch Date: 31-Jan-18
Credits: AMA PRA Category 1 Credit
1 ANCC contact hour
Expiration Date: 30-Jan-19
Curriculum Name: Treating the Underlying Cause of Gout in Primary Care to Prevent Acute Attacks

Learning Objectives

After completing this activity, the participant will demonstrate the ability to:

  1. Make a definitive diagnosis of gout
  2. Design a comprehensive treatment plan, incorporating pharmacologic and nonpharmacologic strategies, to address the chronic nature of gout and to establish cure as the optimal treatment target.
  3. Describe the benefits and risks of appropriate use of available urate-lowering therapies, alone and in combination.
  4. Apply treatment strategies, including use of a treat-to-target approach, to achieve low urate levels, minimize the risk of recurrent gout flares, and manage comorbidities.


    Brian F. Mandell, MD, PhD
    Professor and Chairman of Academic Medicine
    Rheumatic and Immunologic Diseases
    Center for Vasculitis Care and Research
    Cleveland Clinic
    Cleveland, Ohio
    Joan McTigue, MS, PA-C
    Division of Rheumatology
    University of Florida College of Medicine
    VA Medical Center
    ​Gainesville, Florida
    Craig Nielsen, MD
    Department of General Internal Medicine
    Cleveland Clinic
    Cleveland, Ohio
    Educational Needs
    Gout is the most common inflammatory arthritis among adults in Western nations; its prevalence exceeds that of rheumatoid arthritis. A leading risk factor for development of gout is lifestyle, especially excessive intake of purines, alcohol, and fructose. Use of certain medications (eg, diuretics) can increase risk, as can the presence of comorbid conditions including diabetes, metabolic syndrome, hypertension, cardiovascular disease, and chronic kidney disease.
    The underlying pathophysiology of gout is well understood. Gout is a disease of crystal deposition caused by persistent elevation of serum uric acid (SUA) levels above the saturation point for monosodium urate (MSU) crystal formation. Following a period of asymptomatic hyperuricemia, sodium urate crystals gradually accumulate in and around peripheral joints, tendons, and bursae. This accumulation is initially "silent" – that is, it does not cause symptoms – but over time, as urate crystals are shed from articular cartilage into the joint spaces, patients typically experience acute attacks, or flares, of painful synovitis. Left unchecked, this buildup of MSU crystals induces inflammation and eventually causes accumulations of densely packed crystals (tophi) on articular cartilage and bone, resulting in irreversible joint damage, pain, and other chronic symptoms. Clinicians need to be aware that appropriate use of therapies designed to lower SUA levels to a target of ≤6 mg/dL not only prevents flares but can in many cases can result in a cure.
    Joint Accreditation Statement
    In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and Global Academy for Medical Education. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
    Physician Continuing Medical Education
    The Postgraduate Institute for Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
    Continuing Nursing Education
    The maximum number of hours awarded for this Continuing Nursing Education activity is 1.0 contact hours.
    Designated for 1.0 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
    Term of Offering
    This activity was released on January 31, 2018 and is valid for one year. Requests for credit must be made no later than January 31, 2019.
    Instructions for Obtaining Credit

    In order to receive credit, participants must complete the online evaluation and post-test at the end of this program. Participants must also score at least a 70% on the post-test. Statements of credit will be issued upon completion of the evaluation and post-test. 

    Fee Information & Refund/Cancellation Policy
    There is no fee for this educational activity.

    Statement of Support
    This activity is supported by an independent educational grant from Ironwood Pharmaceuticals. 
    Disclosure Declarations

    Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high-quality CME/CE activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
    The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity:
    Name of Faculty or Presenter
    Reported Financial Relationship
    Brian F. Mandell, MD, PhD
    Grant/Research Support and Consultant: Horizon
    Joan McTigue, MS, PA-C
    Nothing to disclose
    Craig Nielsen, MD
    Nothing to disclose

    The planners and managers reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME/CE activity:
    Name of Planner or Manager Reported Financial Relationship
    Mike LoPresti Nothing to disclose
    Margaret McLaughlin, PhD Nothing to disclose
    Ron Schaumburg Nothing to disclose
    The following PIM planners and managers, Trace Hutchinson, PharmD; Samantha Mattiuchi, PharmD, CHCP; Judi Smelker-Mitchek, RN, BSN; and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/life partner do not have any financial relationships to products or devices with any commercial interest related to the content of this activity during the past 12 months.

    Disclosure of Unlabeled Use
    This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration. The planners of this activity do not recommend the use of any agent outside of the labeled indications. 
    The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

    Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.
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    Supported Phones & Tablets:
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