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2008-225.mayThe Journal of Rheumatology
Volume 36, no. 1
Acute Gouty Arthritis After Taking Sildenafil: An Old Disease with a NewEtiology WEI-LIANG CHEN, HONG-I CHEN and CHING-HUI LOH 1. Sign up for our monthly e-table of contents 3. Have us contact your library about access options 4. Information on permissions/orders of reprints is a monthly international serial edited by Earl D.
The Journal of RheumatologySilverman featuring research articles on clinical subjects from scientists working in rheumatology and related fields. Acute Gouty Arthritis After Taking Sildenafil: An Old
examination was unremarkable and his uric acid level was 4.6 mg/dl with- Disease with a New Etiology
It is tempting to speculate that sildenafil induced gout episodes in this case because this has not been documented in any report. In addition, gout Sildenafil citrate (Viagra), a selective inhibitor of cyclic guanosine flares are often observed when urate-lowering therapy has been started or monophosphate (cGMP)-specific phosphodiesterase type 5, is an effective stopped. The temporal sequences in this case do not absolutely preclude treatment for male erectile dysfunction. By enhancement of the effect of this as an explanation of the gout flares. However, the temporal association nitric oxide and cGMP, it leads to smooth-muscle relaxation and inflow of between administration of sildenafil and episodes of acute gouty arthritis blood to the corpus cavernosum1. Sildenafil has suitable pharmacodynam- implies a causal relation. The recurrence of acute arthritis after taking ic and pharmacokinetic properties for use as an oral therapeutic drug for sildenafil (rechallenge test) also suggests a causal relation. Gouty arthritis erectile dysfunction2. Numerous adverse reactions to sildenafil have been is listed as one of many side effects (Viagara package insert; Pfizer Inc.), reported, including headache, facial flush, dyspepsia, nasal stuffiness, and so it must have been detected during the phase III clinical trial. In addition, conjunctival suffusion. However, there have been no reports that sildenafil an unpublished safety surveillance and reporting from Pfizer Inc. describes is associated with acute gout. We describe a 41-year-old man who devel- 7 adverse events with gout attacks during use of sildenafil5.
oped gouty arthritis after taking sildenafil. There was a temporal relation Sildenafil has been widely prescribed; in the absence of evidence from between the attacks of gouty arthritis and administration of sildenafil.
reports in the literature it is imperative to be aware of this problem. We con- Symptoms then subsided after the withdrawal of sildenafil. The symptoms clude that sildenafil can induce acute gouty arthritis, and any physician did recur when he took sildenafil again (positive rechallenge test).
encountering a case with acute arthritis of primary gout will need to sus- Recognizing the possible association and prompt management will prevent pect the possibility of this etiology. The lack of this awareness may result in delay recognizing the etiology and providing prompt management.
A previously healthy 41-year-old man with no significant medical his- tory presented to our outpatient department (first visit) with sudden onset WEI-LIANG CHEN, MD, Department of Family Medicine and of severe exquisite pain and swelling at the metatarsophalangeal (MTP) Community Health; HONG-I CHEN, MD, PhD, Division of Urology; joint of the right hallux. He had had 6 or 7 similar attacks in the past 5 CHING-HUI LOH, MD, PhD, Department of Family Medicine and months. He had visited 3 primary care physicians, who prescribed “pain Community Health, Tri-Service General Hospital, National Defense killers” for his acute symptoms. He specifically denied illicit drug use.
Medical Center, Number 325, Section 2, Cheng-Kung Road, Neihu 114, There was no contributory family history or drug and food allergy history.
Taipei, Taiwan. Address reprint requests to Dr. Loh; Examination showed tenderness, swelling, and redness over the MTP joint.
Laboratory data revealed normal findings except his serum level of uricacid was 9.0 mg/dl (reference value < 7.0). Based on the diagnostic crite- REFERENCES
ria of the American Rheumatism Association3, he was diagnosed as having 1. Boolell M, Gepi-Attee S, Gingell J, Allen M. Sildenafil, a novel acute gouty arthritis at second visit. By taking sulindac and colchicine, fol- effective treatment for male erectile dysfunction. Br J Urol lowed by uric acid-lowering agents (benzbromarone), he had been able to have 2–3 weeks symptom-free. Then he presented (third visit) at the out- 2. Boolell M, Allen MJ, Ballard SA, et al. Sildenafil: an orally active patient department and asked to see the attending physician (CHL) pri- type 5 cyclic GMP-specific phosphodiesterase inhibitor for the vately. He stated he had had another attack of acute arthritis, which he treatment of penile erectile dysfunction. Int J Impot Res 1996; believed was because he had taken 50 mg sildenafil one night before. He also recalled that there had been a temporal relation between the use of 3. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF.
sildenafil and the previous episodes of attacks. He was advised not to take Preliminary criteria for the classification of the acute arthritis of sildenafil until we consulted other specialists.
primary gout. Arthritis Rheum 1977;20:895-900.
An extensive literature review failed to find any report relating silde- 4. Loh CH, Cang YW, Liou SH, Chang JH, Chen HI. Case report: nafil use and gouty arthritis. Confirmation of acute arthritis of gout related hexachloroethane smoke inhalation: a rare cause of severe hepatic to sildenafil by rechallenge test would be reliable but unjustifiable4. Three injuries. Environ Health Perspect 2006;114:763-5.
weeks later (fourth visit), he again developed painful swelling at the same 5. D’Amato S, Hassett J. Summary bridging report: Sildenafil, safety location one day after taking sildenafil 50 mg. Synovial fluid analysis con- surveillance and reporting. New York: Pfizer Inc.; 2006.
firmed the presence of monosodium urate crystals. After treatment, he hasbeen symptom-free with discontinuation of sildenafil for more than 2 J Rheumatol 2009;36:1; doi:10.3899/jrheum.080572 months since that episode. In December 2007 (fifth visit), a followup Personal noTogy Copyright 2009. Al rights reserved.
The Journal of Rheumatology 2009; 36:1
Report for Brighton and Hove Health and Wellbeing Board (HWBB) and Clinical Commissioning Group (CCG) 9.8.13 By John Kapp, 22, Saxon Rd Hove BN3 4LE, 01273 417997, email@example.com CURING THE NHS AND DEPRESSED PATIENTS BY MASS-COMMISSIONING THE MINDFULNESS COURSE The crisis in the NHS is caused by the following factors, which can be solved locally by councillors initiating culture change