36. Gout Flashcards
A patient gave the pharmacist a prescription for Zyloprim 100 mg daily. Which of the following is an appropriate generic substitution for Zyloprim?
A. Allopurinol
B. Probenecid
C. Pegloticase
D. Colchicine
E. Febuxostat
A. Allopurinol is the generic name for Zyloprim.
Chronic urate lowering therapy (ULT)
1st line are XO inhibitors (allopurinol, febuxostat): xanthine oxidase inhibitors that block uric acid production
2nd line is probenecid (can be combined with XO inhibitors)
Pegloticase is reserved for severe, refractory disease
allopurinal (Zyloprim, Aloprim, Lopurin): start low, titrate up. Warning: hypersensitivity reactions, severe rash (SJS/TEN), test for HLA-B*5801 prior to starting, hepatotoxicity. SE: rash, acute gout attacks, nausea, diarrhea, increase LFTs
febuxostat (Uloric): CI when used with azathioprine or mercaptopurine. Warning: hepatotoxicity, increase in thromboembolic events. SE: increase LFTs, rash. Very expensive, no dose reduction in renal impairment, reduced risk of hypersensitivity reactions compared to allopurinol.
A patient is going to use a medication to reduce the incidence of future gout attacks. Which agent/s could be selected for gout prophylaxis? (Select ALL that apply.)
A. Allopurinol
B. Probenecid
C. Prednisone
D. Febuxostat
E. Naproxen
A, B, D. Allopurinol and febuxostat are considered first-line agents for gout prophylaxis. Probenecid is an alternative option for underexcreters.
Chronic urate lowering therapy (ULT)
1st line are XO inhibitors (allopurinol, febuxostat): xanthine oxidase inhibitors that block uric acid production
2nd line is probenecid (can be combined with XO inhibitors)
Pegloticase is reserved for severe, refractory disease
allopurinal (Zyloprim, Aloprim, Lopurin): start low, titrate up. Warning: hypersensitivity reactions, severe rash (SJS/TEN), test for HLA-B*5801 prior to starting, hepatotoxicity. SE: rash, acute gout attacks, nausea, diarrhea, increase LFTs
febuxostat (Uloric): CI when used with azathioprine or mercaptopurine. Warning: hepatotoxicity, increase in thromboembolic events. SE: increase LFTs, rash. Very expensive, no dose reduction in renal impairment, reduced risk of hypersensitivity reactions compared to allopurinol.
probenecid: Inhibits reabsorption of uric acid in kidneys, which increase uric acid excretion. CI: concomitant aspirin therapy, blood dyscrasias, uric acid kidney stones, children
A patient is having an acute gout attack. As an alternative to colchicine, which of the following treatment options can be recommended to help treat the acute pain and inflammation? (Select ALL that apply.)
A. Febuxostat
B. Naproxen
C. Allopurinol
D. Prednisone
E. Ibuprofen
B, D, E. Allopurinol and febuxostat are not used for acute gout treatment; it is used for prophylaxis (or prevention) of future gout attacks.
Treat acute attacks, prevent future flare-ups, and reduce uric acid levels. Drugs used to treat an acute attack (colchicine, NSAIDs, steroids) are different than drugs used to prevent attacks.
colchicine (Colcrys): Treatment: 1.2mg PO (this is two 0.6mg tabs) followed by 0.6mg in 1 hr (not to exceed total of 1.8mg), dose to be repeated no earlier than 3 days (2 weeks in severe renal impairment). Prophylaxis: 0.6mg once or twice daily (0.3mg daily in severe renal impairment). CI with use of P-gp or strong CYP 3A4 inhibitor in the presence of renal/hepatic impairment. Max dose is 1.2mg for acute treatment while on moderate CYP3A4 inhibitor. Warning: blood dyscrasias, gastrointestinal symptoms (NVD), neuromuscular toxicity (rhabdomyolysis), concomitant cyclosporine, diltiazem, verapamil, fibrates, statins. SE: diarrhea, nausea, vomiting, decrease vitamin B12, myelosuppression, myopathy, neuropathy. Recommended only when treatment is started within 36H of onset.
NSAIDs: avoid in severe renal disease, CVD risk
indomethacin (Indocin): most lipophilic of all NSAIDs, floods CNS and cause CNS problems, highest GI toxicity
naproxen (Naprosyn):
sulindac (Clinoril):
celecoxib (Celebrex):
A patient has been given a prescription for colchicine 0.6 mg #12. Choose the correct dosing regimen for colchicine:
A. 1.8 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 2.4 mg - or 3 doses)
B. 1.8 mg orally followed by 0.6 mg in 1 hour x 2 (not exceed a total of 3.2 mg - or 4 doses)
C. 1.2 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 1.8 mg - or 3 doses)
D. 0.6 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 1.2 mg - or 2 doses)
E. 1.8 mg orally X 1 dose
C. Colchicine (Colcrys) is taken at the first sign of an acute flare. Instructions are to take two of the 0.6 mg tablets. Another tablet can be taken in one hour. Three tablets, or 1.8 mg total dose, is the maximum per treatment. If the patient gets GI side effects after the initial dose they should not use the third tablet.
Chronic urate lowering therapy (ULT)
1st line are XO inhibitors (allopurinol, febuxostat): xanthine oxidase inhibitors that block uric acid production
2nd line is probenecid (can be combined with XO inhibitors)
Pegloticase is reserved for severe, refractory disease
allopurinal (Zyloprim, Aloprim, Lopurin): start low, titrate up. Warning: hypersensitivity reactions, severe rash (SJS/TEN), test for HLA-B*5801 prior to starting, hepatotoxicity. SE: rash, acute gout attacks, nausea, diarrhea, increase LFTs
febuxostat (Uloric): CI when used with azathioprine or mercaptopurine. Warning: hepatotoxicity, increase in thromboembolic events. SE: increase LFTs, rash. Very expensive, no dose reduction in renal impairment, reduced risk of hypersensitivity reactions compared to allopurinol.
A patient with gout begins allopurinol 100 mg daily. The patient should be instructed to watch for this adverse effect, and to be seen promptly if it appears serious:
A. Bloody diarrhea
B. Weakness, malaise
C. Rash
D. Mental confusion and dizziness
E. Allopurinol is safe in all patients and has no risk of significant safety concerns
C. Although uncommon, this drug can cause rash which may be benign but can rarely develop into more serious reactions including toxic epidermal necrolysis or Steven-Johnson Syndrome. These can be fatal skin reactions.
allopurinal (Zyloprim, Aloprim, Lopurin): start low, titrate up. Warning: hypersensitivity reactions, severe rash (SJS/TEN), test for HLA-B*5801 prior to starting, hepatotoxicity. SE: rash, acute gout attacks, nausea, diarrhea, increase LFTs
John is a 54 year-old male with hypertension and renal insufficiency. He presents to the clinic with severe pain and a very swollen big toe. John is diagnosed with gout, and given a ten-day prescription for prednisone. Which of the following are short-term side effects from the use of prednisone? (Select ALL that apply.)
A. Possible blood sugar elevation
B. Feeling “spacey” or irritable
C. Cushingoid side effects
D. Hypotension
E. Insomnia
A, B, E. He would not be at risk for adrenal suppression and consequent Cushingoid symptoms with a short course of therapy.
A pharmacist is going to counsel a patient beginning allopurinol therapy. Which counseling statement should be included?
A. This medication should be taken on an empty stomach.
B. Allopurinol can cause blood pressure changes; hold onto the bed or rail when changing from a sitting to a standing position.
C. If you notice a rash, contact your doctor at once. If the rash looks serious, you should not use the medicine and should be seen right away.
D. This medication should only be administered in a medical office.
E. The brand name of this medication is Colcrys.
C. Hypersensitivity reactions, including severe rash (SJ/S/TEN) can occur with allopurinol.
allopurinal (Zyloprim, Aloprim, Lopurin): start low, titrate up. Warning: hypersensitivity reactions, severe rash (SJS/TEN), test for HLA-B*5801 prior to starting, hepatotoxicity. SE: rash, acute gout attacks, nausea, diarrhea, increase LFTs
The use of probenecid can block renal clearance of some of the drugs that are cleared by the kidneys. Which of the following agents may have decreased clearance if taken in a patient using probenecid? (Select ALL that apply.)
A. Aspirin
B. Ampicillin
C. Methotrexate
D. Clopidogrel
E. Amoxicillin
A, B, C, E. Probenecid can block renal clearance of penicillins, methotrexate, theophylline and aspirin.
probenecid: Inhibits reabsorption of uric acid in kidneys, which increase uric acid excretion. CI: concomitant aspirin therapy, blood dyscrasias, uric acid kidney stones, children
Uricosuric agents such as probenecid lower uric acid levels in the body by increasing the elimination of uric acid. These agents are not useful in many patients with gout since they require adequate:
A. Liver function
B. Renal function
C. Pulmonary function
D. Adherence
E. None of the above; probenecid is the drug of choice for most patients with gout who require a daily medication to lower uric acid.
B. Uricosuric agents such as probenecid lower uric acid levels in the body by increasing the elimination of uric acid. These agents are not useful in many patients with gout since they require adequate renal function.
Chronic urate lowering therapy (ULT)
1st line are XO inhibitors (allopurinol, febuxostat): xanthine oxidase inhibitors that block uric acid production
2nd line is probenecid (can be combined with XO inhibitors)
probenecid: Inhibits reabsorption of uric acid in kidneys, which increase uric acid excretion. CI: concomitant aspirin therapy, blood dyscrasias, uric acid kidney stones, children
John is a 54 year-old male with hypertension and renal insufficiency. He presents to the clinic with severe pain and a very swollen big toe. John is diagnosed with gout, and given a prescription for prednisone. Which lab value is likely to be high in this patient?
A. Uric acid
B. Troponin
C. Platelets
D. Calcium chloride
E. Rheumatoid factor
A. Gout is caused by elevated uric acid in the joints. The uric acid crystallizes causing a very painful presentation. A painful, swollen big toe, or metatarsophalangeal joint, is a typical presentation for acute gout.
What is the rationale in using colchicine or an NSAID while beginning allopurinol therapy?
A. To reduce the risk of an acute flare
B. To reduce the risk of renal damage
C. To reduce the risk of mild or severe rash
D. To reduce the risk of crystallization in the urine
E. None of the above
A. NSAIDs or colchicine are used to reduce the risk of an acute flare while beginning uric-acid lowering therapy. It sounds counter-intuitive, but when beginning a potent agent such as allopurinol to lower uric acid, the patient may get an acute flare.
Which analgesic should not be recommended to help with the pain of an acute gout attack as it may increase uric acid levels?
A. Bufferin
B. Ibuprofen
C. Naproxen
D. Sulindac
E. Celecoxib
A. This contains aspirin.
Risk factors: male sex, obesity, excessive alcohol, hypertension, chronic kidney disease, lead intoxication, advanced age, drugs (high dose aspirin, diuretics, niacin, pyrazinamide, ribavirin, tacrolimus, cyclosporine)
Which of the following are risk factors for the development of gout? (Select ALL that apply.)
A. Hypertension
B. Renal insufficiency
C. Advanced age
D. Obesity
E. Excessive alcohol consumption
A, B, C, D, E. Risk factors include male sex, being overweight, excessive alcohol consumption (particularly beer), hypertension, renal insufficiency, advanced age and using medications that increase uric acid.
Risk factors: male sex, obesity, excessive alcohol, hypertension, chronic kidney disease, lead intoxication, advanced age, drugs (high dose aspirin, diuretics, niacin, pyrazinamide, ribavirin, tacrolimus, cyclosporine)
Which of the following are true regarding pegloticase? (Select ALL that apply.)
A. It should be reserved for refractory cases.
B. It is an inexpensive option for the chronic management of gout.
C. Anaphylactic reactions can occur during infusion.
D. It may be used in combination with allopurinol.
E. The brand name is Krystexxa.
A, C, E. Pegloticase in an expensive IV agent used for refractory gout. Anaphylactic reactions are common; therefore, patients should be premedicated with antihistamines and corticosteroids.
pegloticase (Krystexxa): IV only, refractory cases only; form of uricase, an enzyme which converts uric acid to allantoin (inactive and water soluble metabolite of uric acid), it does not block uric acid formation. Boxed warning: anaphylactic reactions (premedicate with antihistamine and steroid). CI: G6PD deficiency. SE: antibody formation, gout flare, infusion reactions, nausea, bruising, urticaria, erythema, pruritis. Do not use in combination with allopurinol (increased risk of anaphylaxis)
Which of the following dietary recommendations are thought to reduce the risk of future gout attacks? (Select ALL that apply.)
A. Consuming low fat dairy products.
B. Reducing intake of beef, lamb and pork.
C. Reducing intake of fresh fruits and vegetables.
D. Avoiding intake of organ meats, such as chopped liver.
E. Avoiding intake of high-fructose corn syrup.
A, B, D, E. To reduce the risk of recurrent gout attacks patients should avoid organ meats, high-fructose corn syrup and alcohol. Servings of fruit juices, table sugar, sweetened drinks and desserts, salt, beef, lamb, pork and seafood with high purine content (sardines, shellfish) should be limited. Low-fat dairy products, vegetables, hydration, weight loss and exercise are encouraged and may reduce the risk for gout attacks.
Lifestyle modifications: low fat dairy, vegetables, hydration, weight control, smoking cessation, exercise.
