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pharmacotherapy 4270 > 4. Gout MT1 > Flashcards

4. Gout MT1 Flashcards

1
Q

this is an inflammatory disease associated with the deposition of monosodium urate crystals (MSU) in joints and soft tissues due to chronic hyperuricemia

A

gout

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2
Q

this is when the serum is saturated with monosodium urate. concentrations are above/around 416 micromols/L for men and 357 micromols/L for women

A

hyperuricemia

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3
Q

true/false: sustained elevation of serum urate is essential for the development of gout, but hyperuricemia does not always lead to gout

A

true

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4
Q

what are some risk factors for developing gout?

A
  • male gender
  • increased age
  • obesity, sedentary lifestyle
  • consumption of alcohol, surgery beverages, and red meat (food high in purines)
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5
Q

_______ is the final step in the degradation of purines. this has no physiological purpose, and it is a waste product.

A

uric acid

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6
Q

our body makes these endogenously and we can also get them exogenously from food; makes up building blocks of DNA and RNA.

A

purines

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7
Q

hyperuricemia will occur when there is either _______ or ________ of uric acid

A

overproduction or under excretion

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8
Q

this is the less common cause of hyperuricemia; is occurs when there is an issue with the enzyme systems that regulate purine metabolism (increase in PRPP synthase which is a key determinant of purine synthesis in the body and a decrease in HGPRT); usually seen in blood cancers where there is an excessive rate of cell turnover

A

overproduction of uric acid

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9
Q

this is a more common cause of hyperuricemia and gout; 90% of gout patients have a relative decrease in the renal excretion of uric acid for an unknown reason; sodium reapsorbtion may also be linked to this (dehydration - body saves Na which in turn saves uric acid and therefore not as much is excreted); drug can also hinder excretion

A

under excretion of uric acid

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10
Q

what are some common drugs than can modify filtration or uric acid or alter reabsorption

A
  • alcohol
  • cyclosporines
  • diuretics: thiazide (HCTZ, chlorthalidone and indapamide) and loop (furosemide)
  • tacrolimus
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11
Q

what are the 4 different clinical spectrums of gout?

A
  • asymptomatic hyperuricemia
  • acute gouty arthritis (gouty flare)
  • intercritical gout (prophylaxis of flares)
  • chronic gouty arthritis
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12
Q

this is not an indication for uric acid lowering therapy
- try to identify possible cause and eliminate medications that could be contributing
- encourage lifestyle modifications

A

asymptomatic hyperuricemia

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13
Q

this is a rapid localized onset of excruciating pain, swelling and inflammation. the attack is usually monoarticular - most often in the metatarsophalangeal joint (big toe)
insteps > ankles>heels>knees>wrists>fingers>elbows
fever and elevated WBCs may be seen

A

acute gouty arthritis (gouty flare)

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14
Q

does this describe a presumptive or definitive diagnosis?
for typical presentation clinical diagnosis is alone reasonable (elevated serum uric acid + inflammation/pain of the big toe)

A

presumptive diagnosis

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15
Q

does this describe a presumptive or definitive diagnosis?
presence of crystals in the synovial fluid

A

definitive diagnosis

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16
Q

treatment for an acute episode of gout should be treated within ____ hours of symptom onset

A

24

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17
Q

what are the three options for treating an acute episode of gout?

A
  • nsaids
  • colchicine
  • corticosteroids
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18
Q

ture/false: treatment options (e.g. NSAIDS, colchicine and corticosteroids) can be combined in order to treat an acute episode of gout in those with severe gout

A

true BUT avoid the use of an oral steroid + NSAID due to increased risk of GI adverse effects

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19
Q

true/false: you should not use NSAIDs concomitantly, even with low dose aspirin

A

false - can use with appropriately indicated low dose ASA

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20
Q

what are the most commonly used NSAIDs for gout?

A

indomethacin
naproxen
ibuprofen
celecoxib

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21
Q

if a patient is taking an NSAID for an acute gout flare, how long after starting the NSAID should they wait to see a HCP if the pain doesn’t get better

A

5-8 days

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22
Q

this medication is only effective if its started within 36 hours of symptoms, with the greatest efficacy seen in the first 24 hours of symptom onset

A

colchicine

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23
Q

what is the dosing for a otherwise healthy patient of colchicine

A

1.6mg stat, then 0.6mg 1 hour later. then in 12 hours 0.6mg daily or BID until gout attack is resolved

24
Q

what is the dose of colchicine for elderly patients with decreased renal function or patients of p-glycoprotein inhibitors

A

0.6mg stat then 0.3mg PO every other day

25
Q

what are some common adverse effects of colchicine

A

n/v, abdominal pain and cramps, diarrhea

26
Q

what are some rare side effects of colchicine

A

neuropathy, myopathy, bone marrow suppression

27
Q

Colchicine may interact with ______ as it may increase HMG-CoA reductase inhibitors - monitor for muscle pain & weakness

A

statins

28
Q

decrease dose and monitor for colchicine toxicity (e.g. GI symptoms, fever, leukopenia) if also taking known inhibitors of ______ (e.g. antiretrovirals, macrolides, itraconazole, ketoconazole, verapamil) or p-glycoprotein inhibitors (e.g. cyclosporine)

A

cyp3A4

29
Q

what is an auxiliary label + counselling point for patients when taking colchicine (dietary)

A

avoid grapefruit juice

30
Q

this medication for an acute gout flare is usually reserved for patients who can’t take NSAIDs or can tolerate colchicine/it doesn’t work.

A

corticosteroids

31
Q

what are some non-pharmacological measures for patients regarding prophylaxis of gout attacks

A
  • switch/eliminate medications that induce hyperuricemia
  • encourage weight loss
  • limit alcohol intake (especially avoid during acute attacks or if gout is poorly controlled)
  • exercise regular
  • smoking cessation
  • avoid organ meats high in protein (e.g. liver, kidney)
  • avoid food and beverages high in fructose and corn syrup
  • limit intake of beef, lamb, pork &n seafood high in purines (sardines and shellfish)
  • limit consumption of table salt, table sugar and desserts
  • encourage low fat or non-fat dairy products
32
Q

when is urate lowering therapy (ULT) indicated?

A
  • more than 2 gout attacks per year
  • presence of tophus/tophi
  • presence or history of uric acid stones
  • reduced kidney function (Cr less than 90 mL/min)
33
Q

this is the first line choice. when starting it, you should START LOW AND GO SLOW.

A

allopurinol

34
Q

allopurinol is started off at 100mg in an otherwise healthy individual. at what intervals should the dose be increased if necessary

A

q 2-4 weeks

35
Q

what is the maximum daily dose in allopurinol

A

800mg/day - should be in divided doses to decrease GI side effects

36
Q

what patients are at an increased risk of a hypersensitivity reaction

A

elderly, those with chronic kidney disease or hepatic impairment

37
Q

true/false: Allopurinol should be dose reduced in those with renal impairment

A

true

38
Q

what are some common (not serious) adverse effects of allopurinol

A
  • maculopapular skin rash (non-life threatening - only seen in ~ 2% of patients)
  • GI upset (Take with food)
  • can precipitate a gout attack
39
Q

what are some serious adverse effects of allopurinol

A
  • Skin reactions usually accompanied by fever, eosinophilia, hepatic and renal dysfunction and rash such as:
    1. allopurinol hypersensitivity syndrome
    2. Steven-Johnson syndrome
    3. toxic epidermal necrosis
    4. drug rash with eosinophilia & systemic symptoms (DRESS)
40
Q

if a patient experiences a itchy rash when taking allopurinol, what should you advise the patient to do?

A

stop taking the drug and contact HCP immediately

41
Q

what are some medications that interact with allopurinol?

A
  • azathioprine & mercaptopurine - thiopurine toxicity = bone marrow suppression
  • amoxicillin/ampicillin (maculopapular rash)
  • thiazides (maculopapular rash)
  • antacids (maculopapular rash)
  • ACEi (maculopapular rash)
  • warfarin (increased INR)
  • cyclophosphamide (oncology drug - increased risk for toxicity)
42
Q

this prophylaxis agent is usually used in patients with renal insufficiency or if desired symptom control is not achieved with allopurinol; significantly more expensive that allopurinol

A

febuxostat (ULORIC)

43
Q

true/false: febuxostat needs to be adjusted for those with compromised renal function

A

false - no adjustment necessary for those with compromised renal function, but there is no information on use in those with renal function less than 30ml/min

44
Q

true/false: febuxostat may cause more acute gout flares during initiation than allopurinol

A

true

45
Q

what drug interactions are there with febuxostat

A
  • azathioprine & mercaptopurine (contraindicated)
46
Q

what are some adverse effects associated with febuxostat?

A
  • abnormalities in LFTs
  • GI upset (N/D)
  • skin rash at higher doses (not life threatening)
  • may increase risk of MI & stroke?
47
Q

what should be monitored when patients are started on allopurinol and febuxostat?

A
  • Uric acid levels and renal function
    every 2-4 weeks during dose titration and then every 3-6 months after target reached
    if on febuxostat, LFTs should be monitored every 2-4 months and then periodically
48
Q

this prophylaxis agent increases the renal clearance of uric acid by inhibiting renal tubular reabsorption of uric acid; the use of this class of drugs should be avoided in patients with a history of urolithiasis (formation of stony concretions in the bladder or urinary tract) and if their CrCL is < 50 mL/min

A

uricosuric agents

49
Q

this prophylaxis agents is a uricosuric agent that is usually only used when allopurinol/febuxostat therapy has failed or is contraindicated. it is only available throughout the healthy Canada special access program

A

probenecid

50
Q

these two medications have been used adjectivally with xanthine oxidase inhibitors (allopurinol and febuxostat) for prophylaxis of gout

A

fenofibrate and Losartan

51
Q

if a patient has renal impairment (CrCl < 90ml/min) what should be used and what should be avoided for acute treatment

A
  • colchicine and corticosteroids preferred
    -avoid NSAIDs
52
Q

if a patient has renal impairment (CrCl < 90ml/min) what should be used for prophylaxis treatment and are dosage adjustments necessary?

A
  • allopurinol: dosage adjustment with severe kidney disease
  • febuxostat: no dosage adjustment necessary if CrCl 30-90 ml/min
53
Q

if a patient has cardiovascular comorbidities, what should be used and what should be avoided for acute treatment

A
  • colchicine preferred
  • avoid NSAIDs and avoid steroids in patients with heart failure
  • remember if pt has high blood pressure, and NSAIDs are acute tx - MONITOR BP
54
Q

if a patient has cardiovascular comorbidities, what should be used and what should be avoided for prophylaxis therapy?

A
  • based on CARES trial? avoid febuxostat
  • allopurinol should be started at a low dose (50mg) and titrated slowly
55
Q
A
56
Q
A

pharmacotherapy 4270 (19 decks)

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