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From Science to Practice - Gout Case Study in Primary Care

Treating the Underlying Cause of Gout in Primary Care to Prevent Acute Attacks
1 ANCC Contact Hours 1 AMA PRA Category 1 Credit(s)
Launch Date:
January 31, 2018
Expiration Date:
The accreditation for this activity has expired.

Primary Audience:

Primary Care Physicians, Internal Medicine, General Practice, Nurses, Physician Assistants

Relevant Terms:

Gout, tophi, serum uric acid

Brian F. Mandell, MD, PhD

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

Brian Mandell is chairman of academic medicine and a senior staff in Rheumatology and Immunologic Diseases, Center for Vasculitis Care and Research at the Cleveland Clinic in Cleveland, Ohio.
Dr. Mandell joined the Clinic in 1993 following a faculty appointment at the Hospital of the University of Pennsylvania. He previously earned a bachelor's degree in Biology and a Ph.D. in Physiology and Biophysics from Washington University, St. Louis, Missouri, and then a medical degree from New York University School of Medicine. He trained in medicine and rheumatology at the University of Pennsylvania. He is board certified in internal medicine and rheumatology, and was awarded Mastership in the American College of Physicians.
He is currently editor-in-chief of the Cleveland Clinic Journal of Medicine and is a professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is a graduate of the Stanford Faculty Development Program in clinical teaching.
Dr. Mandell has served on national education planning and writing committees for the American College of Rheumatology, the American Board of Internal Medicine and the American College of Physicians.
He has published over 100 articles, chapters, and editorials in peer-reviewed publications and textbooks relating to clinical and basic aspects of medical science. He has a special interest in gout as well as multi-system inflammatory diseases.

Joan McTigue, MS, PA-C

Joan McTigue, MS, PA-C
Division of Rheumatology
University of Florida College of Medicine
VA Medical Center
​Gainesville, Florida

Joan McTigue is a physician assistant in the division of rheumatology at the University of Florida College of Medicine and the VA Medical Center in Gainesville, Florida. In addition, she is a board member of the Gout & Uric Acid Education Society.
Ms McTigue's area of interest is patient education and patient advocacy. She has been on the board of directors for several community and educational nonprofit organizations including Gainesville Women's Health Center and the Gainesville chapter of The Arthritis Foundation. She is currently the associate scientific editor for the American College of Rheumatology web based post-graduate rheumatology training program for physician assistants and nurse practitioners.
Ms McTigue also is on the editorial staff of ADVANCE for Physician Assistants and a peer reviewer for The Journal of the American Academy of Physician Assistants. She has authored numerous articles and has been a study coordinator or co-investigator on numerous research projects in both women's health and rheumatology.
Ms McTigue received her bachelor's degree in health science from State University of New York in Stony Brook, New York, and a master's in health science from University of Nebraska in Omaha, Nebraska.

Craig Nielsen, MD

Craig Nielsen, MD
Department of General Internal Medicine
Cleveland Clinic
Cleveland, Ohio

Craig Nielsen, MD, FACP, is a staff physician in the Department of General Internal Medicine, located on the main campus of Cleveland Clinic. He was appointed in 2002 subsequent to serving as associate staff physician, assistant staff physician and clinical associate of that department.

In addition to his current appointment, he also serves as program director of the Cleveland Clinic Internal Medicine Residency Program, Vice Chairman of Education for the Medicine Institute, Vice Chairman of the Department of Internal Medicine and Assistant Professor of Medicine, Case Western Reserve School of Medicine, Cleveland. Dr Nielsen is board-certified in internal medicine by the American Board of Internal Medicine. His special interests include preventive medicine, alcoholism, diabetes, and men's health.

Dr Nielsen received his medical degree from the University of Vermont College of Medicine, Vermont. He has been named as a "Top Doc" by Cleveland Magazine from 2006 to 2011. In 2009, Dr. Nielsen was recognized by the National Committee for Quality Assurance (NCQA) for the quality of his care of diabetics (Diabetes Physician Recognition Program).

He has authored and presented a broad range of topics including hypertension, alcoholism, cervical cancer screening, preventive medicine, suicide and medical education. Dr Nielsen is a member of the Medical Student Promotion and Review Committee, the Governor's Advisor Council of the Ohio Branch of the American College of Physicians (ACP), and the Cleveland Clinic Graduate Medical Education Committee, among others.
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.

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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