|
|
|
|
|
Search
05/26/2022 Charles Morelli, DPM
Treating Hyperuricemia (Martin Thomas Girling, DPM)
I agree with Dr. Girling that “Our job is clear,
our license is not” and I do whatever it is I can,
within the scope of my license and my education
but there are times when other PCPs and
rheumatologists do not treat a patient properly or
aggressively enough to take care of their initial
symptoms. I just had a patient this morning that
came in and told me that their doctor told them
that they have gout and s/he gave them 100mg of
Allopurinol. No blood test, no x-ray, no previous
history. Just that their toe was painful, and this
happens all of the time. This patient needed
colchicine and steroids initially
As an aside, I have also had many patients over
the years who were told that they have psoriatic
arthritis. No skin lesions, no nail changes, no
negative RF or x-rays changes (joint swelling,
dactylyitis) and no family history of psoriasis.
Yet they are told they have PA. Maybe someone can
explain this to me please.
In the same way that there are many in our
profession who would never dream of prescribing
terbinafine, there are others who would never
dream of prescribing colchicine or allopurinol,
and wouldn’t dream of treating a patient who (as
Dr. Girling describes) “had tophi on his face,
arms, feet, and chest. I have seen small tophus
resolve with oral meds, but these patients need to
be referred to an infusion center for weekly
treatments with Krystexa (assuming they have
failed allopurinol and do not have a G6PD
deficiency opr any other contra-indication). We
should be doing this routinely, but not
unilaterally. I always let the rheumatologist or
PCP know what my findings were, what my treatment
plan is and I have been thanked each and every
time and my treatment regimen and plan has never
been rescinded ,and now my local PCP community
feels comfortable referring these patients to me.
We are their first line of defense for the acute
manifestation, mainly because it is almost
impossible for any patient to get an appointment
and see their rheumatologist when they are
experiencing an acute attack, whereas getting an
appointment with their podiatrist may be easier.
Take a proper history, get blood work, rule out
the most common etiologies of CKD, dehydration /
diuretics, high fructose corn syrup, wheat based
beer and lastly, diet. CKD can be diagnosed,
dehydration from diuretics can be treated in many
cases by switching over to Cardizem (discuss with
cardiologist), and the rest are life style
modifications.
Many people are yelling about a degree change from
DPM to MD and attaining parody with MDs. How about
we start by attaining the testicular fortitude to
write for medications first, and the rest of the
parody will follow. We have no problem writing for
antibiotics and NSAIDs that can cause renal
failure and ototoxicity, but writing for
terbinafine, colchicine, and allopurinol?
Charles Morelli, DPM, Mamaroneck, NY
Other messages in this thread:
05/31/2022 Elliot Udell, DPM
Treating Hyperuricemia (Martin Thomas Girling, DPM)
This conversation on the prescribing of urate-
lowering medications is not a new one, with many
saying yea and others saying nay. The crux of the
controversy is whether treating hyperuremia is
addressing a systemic condition or a local
manifestation of gout. Those who argue that it’s
systemic are quick to equate it with the
management of diabetes. There are distinct
differences between the two ailments. For example,
if a patient presents with acute gout affecting an
elbow or has hyperuricemia with no clinical
manifestations, treating it or even telling a
patient not have it treated would be out of scope
for us.
On the other hand, if a patient has pedal
manifestations of gout and there is a direct link
between the symptoms and hyperuricemia then it may
very well fall under the scope of podiatry and
many internists will expect podiatrists to include
uric acid-lowering agents in his or her treatment
of gout. As pointed out in other comments, some
would consider it an annoyance if he or she had to
see a patient just to write for allopurinol.
This same thinking would apply to the prescribing
of “Augmentin “for a foot infection. That same
drug would not be allowed to be prescribed by a
podiatrist if the patient was presenting with just
a throat infection. Yes, diabetes can lead to
neuropathy, ulcerations and pedal infections
however the link is not as direct as would be an
interdigital staph infection causing cellulitis or
the case of the person who is constantly
presenting with swollen first met heads as a
direct result of elevated urate levels.
Our profession allows companies that make urate-
lowering drugs to sponsor, present and advertise
at our conventions. You would never see a booth at
a podiatry conference advertising Trulicity For
diabetes.
Elliot Udell, DPM, Hicksville, NY
05/30/2022 Paul Kesselman, DPM
Treating Hyperuricemia (Martin Thomas Girling, DPM)
I applaud all those who have posted their
opinions, but alas, it appears there are two
different issues being presented here. The first
is whether or not podiatrists should be treating
the systemic issues associated with gout. I don't
believe that many orthopedists would do that and
would likely refer the patient to their internist
or other PCP for this. They are too damn busy
fixing knees, hips, etc.
I offer this opinion not as one who is suggesting
doing this will give us parity, but as one who has
worked with a variety of orthopedists, who simply
don't have the time nor do they feel it is within
their skill set to start managing gout I don't
believe that any podiatrist out there should be
looking at this any different than titrating a
patient's oral or injectable hyperglycemic agents.
And in fact many PCP who see a complex diabetic
punt those patients to the endocrinologist. And
for good reason.
It is also likely that many patients with long
term gout have renal issues and they are punted by
the PCP to the nephrologist.
So I subscribe to the share the "wealth" and when
I was in clinical practice felt it was no shame to
refer the patients back to the appropriate
specialist for chronic long term management. I for
one had no issues w/using any short term
medication for treating the "flare". IMO, the
gouty tophi in gout are similar to the elevated BS
in DM. Those are the province of other medical
specialists.
The second and other separate issue is that of
being intimidated in being afraid to treat the
gout flare with Indocin, colchicine, Medrol dose
pack, etc. These are certainly within the
wheelhouse of the podiatric physician and the
podiatrist not willing to offer these short term
treatments to their patients, certainly
is not proving their parity (in my opinion) with
their MD colleagues whether ortho or rheumatology
or even PCP. In fact this is where the DPM should
sign over the PCP. Whereas the PCP may be
intimidated in providing intra articular
injections. That is the DPM as the orthopedic or
rheumatology specialist should be able to
provide these services.
Now there may be times where a complex diabetic
with HTN comes in w/gout and one should have the
foresight to communicate w/the other MD
specialists in terms of titrating medication doses
of steroids and Indocin and scheduling of those
medications. Those other medical specialists
should also be communicating w/their patient on
the issues of managing the other issues (e.g. HTN,
DM) while on the acute gout medications. That is
of course up to the DPM to let the others involved
in the patient's health care of what they are
doing.
As for being "afraid" of treating any and all
patients with terbinafine, in my humble opinion
this is much different than carefully selecting
patients who are multi pharm patients with
significant risk.
I see nothing wrong w/selective prescribing but
see the issue of lack of parity if someone refers
the patient back to the MD/DO PCP or dermatologist
for treatment of a simple case of onychomycosis.
This is again an issue where the DPM should shine.
But again, communicating with the MD in charge of
the patient's overall health care about treatment
is in fact showing parity. That is what MD/DO do
all day. They "share the wealth." And there is
certainly nothing wrong with that.
Paul Kesselman, DPM, Oceanside, NY
05/26/2022 Charles Morelli, DPM
Treating Hyperuricemia (Martin Thomas Girling, DPM)
I agree with Dr. Girling that “Our job is clear,
our license is not” and I do whatever it is I can,
within the scope of my license and my education
but there are times when other PCPs and
rheumatologists do not treat a patient properly or
aggressively enough to take care of their initial
symptoms. I just had a patient this morning that
came in and told me that their doctor told them
that they have gout and s/he gave them 100mg of
Allopurinol. No blood test, no x-ray, no previous
history. Just that their toe was painful, and this
happens all of the time. This patient needed
colchicine and steroids initially
As an aside, I have also had many patients over
the years who were told that they have psoriatic
arthritis. No skin lesions, no nail changes, no
negative RF or x-rays changes (joint swelling,
dactylyitis) and no family history of psoriasis.
Yet they are told they have PA. Maybe someone can
explain this to me please.
In the same way that there are many in our
profession who would never dream of prescribing
terbinafine, there are others who would never
dream of prescribing colchicine or allopurinol,
and wouldn’t dream of treating a patient who (as
Dr. Girling describes) “had tophi on his face,
arms, feet, and chest. I have seen small tophus
resolve with oral meds, but these patients need to
be referred to an infusion center for weekly
treatments with Krystexa (assuming they have
failed allopurinol and do not have a G6PD
deficiency opr any other contra-indication). We
should be doing this routinely, but not
unilaterally.
I always let the rheumatologist or PCP know what
my findings were, what my treatment plan is and I
have been thanked each and every time and my
treatment regimen and plan has never been
rescinded ,and now my local PCP community feels
comfortable referring these patients to me. We are
their first line of defense for the acute
manifestation, mainly because it is almost
impossible for any patient to get an appointment
and see their rheumatologist when they are
experiencing an acute attack, whereas getting an
appointment with their podiatrist may be easier.
Take a proper history, get blood work, rule out
the most common etiologies of CKD, dehydration /
diuretics, high fructose corn syrup, wheat based
beer and lastly, diet. CKD can be diagnosed,
dehydration from diuretics can be treated in many
cases by switching over to Cardizem (discuss with
cardiologist), and the rest are life style
modifications.
Many people are yelling about a degree change from
DPM to MD and attaining parody with MDs. How about
we start by attaining the testicular fortitude to
write for medications first, and the rest of the
parody will follow. We have no problem writing for
antibiotics and NSAIDs that can cause renal
failure and ototoxicity, but writing for
terbinafine, colchicine and allopurinol?
Charles Morelli, DPM, Mamaroneck, NY
05/26/2022 Charles Morelli, DPM
Treating Hyperuricemia (Martin Thomas Girling, DPM)
I agree with Dr. Girling that “Our job is clear,
our license is not” and I do whatever it is I can,
within the scope of my license and my education
but there are times when other PCPs and
rheumatologists do not treat a patient properly or
aggressively enough to take care of their initial
symptoms. I just had a patient this morning that
came in and told me that their doctor told them
that they have gout and s/he gave them 100mg of
Allopurinol. No blood test, no x-ray, no previous
history. Just that their toe was painful, and this
happens all of the time. This patient needed
colchicine and steroids initially
As an aside, I have also had many patients over
the years who were told that they have psoriatic
arthritis. No skin lesions, no nail changes, no
negative RF or x-rays changes (joint swelling,
dactylyitis) and no family history of psoriasis.
Yet they are told they have PA. Maybe someone can
explain this to me please.
In the same way that there are many in our
profession who would never dream of prescribing
terbinafine, there are others who would never
dream of prescribing colchicine or allopurinol,
and wouldn’t dream of treating a patient who (as
Dr. Girling describes) “had tophi on his face,
arms, feet, and chest. I have seen small tophus
resolve with oral meds, but these patients need to
be referred to an infusion center for weekly
treatments with Krystexa (assuming they have
failed allopurinol and do not have a G6PD
deficiency opr any other contra-indication). We
should be doing this routinely, but not
unilaterally. I always let the rheumatologist or
PCP know what my findings were, what my treatment
plan is and I have been thanked each and every
time and my treatment regimen and plan has never
been rescinded ,and now my local PCP community
feels comfortable referring these patients to me.
We are their first line of defense for the acute
manifestation, mainly because it is almost
impossible for any patient to get an appointment
and see their rheumatologist when they are
experiencing an acute attack, whereas getting an
appointment with their podiatrist may be easier.
Take a proper history, get blood work, rule out
the most common etiologies of CKD, dehydration /
diuretics, high fructose corn syrup, wheat based
beer and lastly, diet. CKD can be diagnosed,
dehydration from diuretics can be treated in many
cases by switching over to Cardizem (discuss with
cardiologist), and the rest are life style
modifications.
Many people are yelling about a degree change from
DPM to MD and attaining parody with MDs. How about
we start by attaining the testicular fortitude to
write for medications first, and the rest of the
parody will follow. We have no problem writing for
antibiotics and NSAIDs that can cause renal
failure and ototoxicity, but writing for
terbinafine, colchicine and allopurinol?
Charles Morelli, DPM, Mamaroneck, NY
|
| |
|
|
|
