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CDM 2 > Exam 2: Gout > Flashcards

Exam 2: Gout Flashcards

1
Q

___ is the most common cause of inflammatory arthritis in the US

A

Gout

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2
Q

Hyperuricemia def

A

Elevated serum uric acid

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3
Q

Tophus def

A

A calculus containing sodium urate that develops around fibrous tissue around joins, typically in patients with gout

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4
Q

Podagra def

A

A painful condition of the big toe caused by gout

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5
Q

Uricase def

A

(Urate oxydase)
An enzyme that oxidatively degrades uric acid, thereby catalyzing conversion to soluble allantoin, which is much more soluble than uric acid. Found in most animals but NOT humans

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6
Q

Uricosuric medications

A

Medications administered to increase the elimination of uric acid (usually 10% of uric acid is eliminated renally but meds increase it)

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7
Q

Uric Acid Pathway: Hypoxanthine becomes Xanthine via ___

A

Xanthine oxidase

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8
Q

Uric Acid Pathway: ___ becomes Uric Acid via ___

A

Xanthine becomes UA via Xanthine Oxidase

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9
Q

Uric acid is excreted by ___ in humans and metabolized via ___ in animals

A

Kidney in humans

Urate oxidase in animals

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10
Q

Uric Acid Pathway: Uric acid becomes ____ via _____ in animals

A

Allatonin via urate oxidase

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11
Q

Uric Acid Pathway: The uric acid metabolite, ____ ,is then excreted in the kidneys in ___

A

Allantoin

Animals

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12
Q

Elevated SUA for men

A

> 7mg/dL (416µmol/L at 37º

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13
Q

Elevated SUA for women

A

> 6mg/dL (357µmol/L) at 37º

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14
Q

T/F: All pts with hyperuricemia develop acute gout flares

A

FALSE – if no gout, asymptomatic hyperuricemia does NOT require treatment

Not all pts with gout have hyperuricemia either!

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15
Q

Spectrum of Gout disease

A

Tophi (deposition of MSU in articular and extra-articular space)
Hyperuricemia
Recurrent acute arthritis attacks due to MSU crystals in synovial fluid
Interstitial renal disease (can lead to CKD)
Uric acid nephrolithiasis (kidney stones)

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16
Q

Which best describes gout?

  1. all pts with gout will progress to chronic tophaceous gout
  2. all pts with gout have hyperuricemia
  3. Pts with gout will have recurrent acute attacks separated by intercritical periods
  4. Gout is primarily due to the overproduction of uric acid
A
  1. Pts with gout will have recurrent acute attacks separated by intercritical periods – flares and then gets better and then worse and then better
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17
Q

T/F: Developing countries have higher prevalence of gout than developed countries

A

FALSE – DEVELOPED > developing – remember RF: obesity, overindulgence in foods, HTN, HF, DM, sedentary lifestyle

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18
Q

Risk factors of Gout

A 
Increasing age
M > F
Injury
Hyperuricemia 
Fasting
Recent surgery
Foods/drinks
Medications
Medical conditions
Genetics
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19
Q

Risk factors: foods/drinks

A

High in purines (red meat)
Foods and drinks with high fructose corn syrup (soda, condiments)
Alcohol!! (both acute/chronic intake can increase SUA)

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20
Q

Medication Risk factors: Overproduction

A

Cytotoxic chemotherapy (DNA breakdown, increase SUA)

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21
Q

Medication Risk Facotrs: Underexcretion

A

Cyclosporine and tacro (RF kidney transplants)
Diuretics (loop/thiazide) – increased sodium reabsorption and UA , decreased volume in joints, increased UA saturation
Niacin
Low dose salicylates (<2g/day)
Pyrazinamide
Ethambutol

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22
Q

Medical Condition Risk Factors: Overproduction

A 
Myeloproliferative disorders
Lymphoproliferative disorders 
Malignancy 
Hemolytic disorders
Psoriasis 
Obesity
Tissue hypoxia 
Down syndrome
Glycogen storage diseases (Types III,V,VII)
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23
Q

Medical Condition Risk Factors: Underexcretion

A 
Chronic renal insufficiency 
Lead nephropathy
Volume depletion 
Diabetic or starvation ketoacidosis
Lactic acidosis
Obesity
Hyperparathyroidism
Hypothyroidism
Sarcoidosis
Chronic beryllium disease
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24
Q

Genetic Risk Factors

A

HGPRT deficiency

PRPP over activity

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25
Treatment options for Acute Gouty Attacks
Colchicine, NSAIDs, Corticosteroids, and (IL1 antagonists)
26
Acute Gout presentation
``` Monoarticular arthritis, redness/swelling/inflammation/warmth Fever Elevated SUA Increased WBC MSU in synovial fluid Rapid onset Overnight or after a trigger (alc, meats, diuretics) Excruciating pain ```
27
___ is the gold standard for definitive diagnosis of gout
evidence of MSU crystals
28
Pseudogout is related to ___ crystals while gout is related to ___ crystals
Pseudogout is calcium pyrophsophate crystals | Gout is MSU
29
These 4 diagnoses can be similar to gout
Pseudogout Septic arthritis RA Trauma
30
Acute Gout treatment goals
Rapid symptom relief Prevent recurrent attacks Prevent complications associated with chronic deposition of urate crystals
31
T/F: Acute gout flares are not self-limiting
False - they are self-limiting (but very painful!)
32
All therapy should be initiated within ___ hours of acute gout symptom onset and continued for ____
within 24 hours | Continued for 1-2 weeks
33
Do NOT d/c ____ in an acute attack
ULT
34
Acute Gout treatment options: Self-care
Ice Rest Patient education
35
NSAIDs MOA
Peripheral inhibition of COX leading to inhibition of prostaglandin synthesis
36
Acute Gout: NSAID: Adverse effects
Increased BP Sodium/water retention gastritis GI Bleed
37
Acute Gout: NSAID: CI
Hx of NSAID allergy HF Renal sufficiency Hx of GI ulcer/bleeds/perforations
38
Acute Gout: NSAIDs: DDI
``` ACEI/ARB Cyclosporine Tacrolimus Tenofovir Lithium (can cause lithium toxicity - narrow therapeutic window) Anti-platelet and anticoag Corticosteroids ```
39
Acute Gout: NSAIDs monitoring
``` S/sx of gout, reduced number for flares CBC LFT SCR Fecal occult blood test Black tarry stools BP Edema ```
40
Acute gout: Corticosteroids MOA
Synthetic glucocorticoid analog used for anti-inflammatory effects
41
Which corticosteroid is a good option of pts that have 1-2 joints affected by gout and it is locally administered?
Intra-articular triamcinolone acetonide
42
Acute gout: Corticosteroid ADEs
Acute: Hyperglycemia, leukocytosis, fluid retention, impaired wound healing, GI upset, insomnia, hypertension Chronic: HPA axis suppression, osteoporosis
43
Acute gout: Corticosteroid Precautions
Infection DM Peptic ulcer disease
44
Acute gout: Corticosteroid DDIs
Strong CYP3A4 inhibitors Fluoroquinolone NSAIDs Anti-hyperglycemic agents (DM meds)
45
Acute gout: Corticosteroid Monitoring
``` BG BP Mental status Electrolytes Edema ```
46
Acute gout: Corticosteroid Pt education points
ADEs Monitor glucose if pt with DM Take with food/milk to minimize GI upset
47
Acute Gout: Colchicine MOA
May interfere with the intracellular assembly of the inflammasome complex present in neutrophils and monocytes that mediates the activation of interlukin-1β Disruption of cytoskeletal functions through inhibition of β-tubulin polymerization into microtubules which prevents the activation, degranulation, and migration of neutrophils **not completely sure how it works, essentially reduces inflammatory
48
Compare low and high doses of colchicine
Both gave pain relief but less ADEs with LOW dose
49
Colchicine: PPX of gout flare dosing
0.6mg daily or BID
50
Colchicine: PPX Renal dosing adj?
CrCl <30 -- 0.3mg daily | HD -- 0.3mg twice WEEKLY
51
Colchicine: PPX Hepatic impairment dosing adj?
If severe, consider dose adj or alternative
52
Colchicine: Tx of acute gout flares dosing
1.2mg once then 0.6mg one hour later (max 1.8mg)
53
Colchicine: Tx of Acute Gout Flare renal dosing adj?
No adjustment needed If CrCl <30 -- tx course should not be repeated more than once every 2 weeks HD Single dose 0.6mg and treatment should not be repeated more than once every 2 weeks
54
Colchicine: Tx of acute gout flares hepatic impairment dosing adj?
No adj needed | Severe -- Tx courses should not be repeated more than once every 2 weeks
55
Colchicine: In what situations should treatment courses not be repeated more than once every 2 weeks?
CrCl <30 (severe renal impairment) HD Severe hepatic impairment
56
Colchicine: When should it NOT be used
Combined hepatic and renal impairment
57
Colchicine ADEs
``` GI: DIARRHEA, N/V, ab pain Blood dyscrasias (myelosuppression, leukopenia, granulocytopenia, thrombocytopenia, aplastic anemia) Neuromuscular toxicity (myopathy, rhabdo, muscle weakness/pain) ```
58
Colchicine: CI
Renal or hepatic impairment -- do not use colchicine with PGP or strong CYP3A4 inhibitor Combined renal and hepatic impairment--do not use Gloperba and Mitigare
59
Colchicine brand names
Colcrys, Mitigare, Gloperba
60
Colchicine: DDI
Substrate of CYP3A4 and PGP and Inducer of CYP2C8, 2C9, 2E1, 3A4 3A4 inhibitors: ritonavir, itraconazole, clarithromycin, ketoconazole, grapefruit juice, diltiazem, verapamil PGP inhibitor: Ranolazine, cyclosporine Statins and fibrates (increase risk of myalgia, won't change dosing but monitor)
61
Colchicine: Monitoring
CBC S/sx of muscle toxicity GI symptoms
62
IL1-RA: Anakinra (Kineret) MOA
Competitively inhibits IL-1 from binding to the IL-1 receptor
63
IL1-RA: Canakinumab (Illaris) MOA
Recombinant human anti-human interleukin-1 beta (IL1-B) monoclonal antibody of the IgG1/kappa isotype blocks IL-1 receptor interaction\
64
IL1-RA: Rilonacept (Arcalyst) MOA
Acts as a decoy receptor that binds to IL-1 beta thereby blocking IL1-B interaction; also binds to IL-1 alpha and IL-1 receptor antagonist
65
IL1-RA Agents (3)
Anakinra (Kineret) Canakinumab (Illaris) Rilonacept (Arcalyst)
66
Anakinra brand name
Kineret
67
Canakinumab brand name
Illaris
68
Rilonacept brand name
Arcalyst
69
IL1-RA: Adverse effects
Injection site reactions, neutropenia, hypersensitivity reactions, infectious disease
70
IL1-RA: Contraindications
Hypersensitivity
71
IL1-RA: DDI
Immunosuppressants (prof also mentioned live vaccines)
72
IL-1RA Monitoring
Neurophil count, temperature, s/sx of infxn
73
IL-1RA Pt education points
Report signs/symptoms of an infection, screen for TB infection prior to initiation, avoid live vaccines during therapy, side effects, proper injection technique, leave syringe at room temperature for 30 mins prior to injection (Anakinra)
74
Acute Gout: Joint involvement - polyarticular def
≥4 joints w/arthritis involving more than 1 region (forefoot, midfoot, ankle/hindfoot, knee, hip, fingers, wrist, elbow, shoulder, other) Acute gout attack involving 3 separate large joints
75
Acute Gout: Mild severity range
≤4
76
Acute Gout: Moderate severity range
5-6
77
Acute Gout: Severe severity range
≥7
78
Acute Gout: Early duration
<12h after onset
79
Acute Gout: Well-established duration
12-36h after onset
80
Acute gout: Late duration of gout
>36h after attack onset (colchicine prob not effective at this time)
81
Chronic Tophaceous Gout Presentation
Tophus: urate depostis | Fingers > olecranon bursae > forearm > achilles tendon > knees > wrists > hand
82
Is Chronic Tophaceous Gout common?
late complication of gout, uncommon in the general pop
83
Chronic Tophaceous Gout complications
Joint deformities and destruction Pain Damage to surrounding tissue Nerve compression
84
Chronic Gout: treatment goals
Maintain SUA <6 Reduce tissue level of uric acid Dissolve existing urate crystals Prevent further MSU crystal formation
85
Chronic Gout: Initating ULT strongly recommended for
≥1 tophi Radiographic damage attributable to gout Frequent gout flares ≥2/year
86
Chronic Gout: Initiating ULT conditionally recommended for
Pts with >1 flare but infrequent (<2/year) Pts experiencing first flare and have CKD stage≥3, SUA >9, or urolithiasis (to prevent progression of disease)
87
Chronic Gout: Initiating ULT conditionally recommended AGAINST
Pts with 1st flare with exceptions (sometimes pts get flares once and then never again) Asymptomatic hyperuricemia
88
You should ALWAYS start PPX (low dose NSAIDs/Colchicine/Steroids) prior to or with initiation of ___
ULT
89
Mobilization Flares: PPX should be continued for at least ____
3-6 months
90
ULT Clinical benefit
ULT can reduce flare frequency, resolve tophi, and reduce SUA conc
91
Allopurinol brand name
Zylporim
92
Allopurinol MOA
Xanthine oxidase inhibitors (reduces UA production)
93
Allopurinol dosing
Start 50mg or 100mg po daily, titrate up by 50-100mg every 2-5 weeks until a goal of SUA <6 Doses >300 often given in divided doses, max dose 800mg/day
94
Chronic Gout: Allopurinol renal dosing adj?
Initiation: CKD stage ≥4 -- 50mg Everyone else -- 100mg ≤100mg daily and lower for those with CKD *renal adj only for intiation but not chronic use Chronic: patients with CKD may require dose titration above 300mg/day to reach SU taget
95
Chronic gout: allopurinol hepatic dose adj
No dose adj necessary
96
Chronic Gout: Allopurinol metabolism
Hepatic to active metabolite (oxypurinol)
97
What is the active metabolite of allopurinol?
Oxypurinol
98
Chronic Gout: Allopurinol elimination
Renal
99
Allopurinol ADE
``` Hematologic (agranulocytosis, aplastic anemia, myelosuppression, thrombocytopenia) Renal failure GI (Diarrhea, nausea) Acute gout (mobilization flares) Rash ``` ALLOPURINOL HYPERSENSITIVITY SYNDROME (AHS)
100
Chronic Gout: Allopurinol: AHS prevention
HLA-B*5801 screening
101
Chronic Gout: Allopurinol: AHS manifestation
Rash chills fever leukopenia leukocytosis eosinophilia and pruritus May be severe and FATAL (hepatotoxicity, vasculitis, SJS, and TEN)
102
Chronic Gout: Allopurinol: AHS management
D/C allopurinol at first sign of rash | Supportive care
103
Chronic Gout: Allopurinol CI
allopurinol sensitivity | Concurrent didanosine
104
Chronic Gout: Allopurinol DDI
``` Azathioprine and 6MP (MUST reduce dose of azathioprine and 6MP when used with allopurinol) Didanosine Theophylline Pegloticase Loop/thiazide diuretics ```
105
Chronic Gout: Allopurinol monitoring
HLA-B*5801 prior to initiation in high-risk subpopulations (han chinese, korean, thai, or AA) SCR, CBC, LFTs, rash
106
Chronic Gout: Febuxostat MOA
Non-purine inhibitor of xanthine oxidase (XOI) leading to reduced production of uric acid
107
Febuxostat brand name
Uloric
108
Chronic Gout: Febuxostat dosing
Initiate at 40mg po daily; if goal SUA is not achieved by 2 weeks, increase to 80mg po daily, max dose 80mg in US
109
Chronic Gout: Febuxostat renal/hepatic dosing adj
None for mild-moderate impairment Max 40mg with severe renal impairment
110
Chronic Gout: Febuxostat ADE
Abnormal LFTs Nausea Gout flares due to mobilization Arthralgia, rash
111
Chronic gout: Febuxostat CI
Concomitant use of azathioprine or 6MP
112
Chronic gout: Febuxostat precaution
Acute gout flare Cardiovascular events (BBW) Hepatotoxicity Serious skin reactions
113
Comparing XOI, which is the preferred first-line agent?
Allopurinol
114
Probenecid MOA
Competitively inhibits the postsecretory renal proximal tubular reabsorption of uric acid
115
Probenecid dosing
500g po daily or BID, titrated up to 500-2000mg/day
116
Probenecid brand name
Benamid
117
Probenecid renal dosing adj?
AVOID -- CrCl <50
118
Probenecid ADES
Flushing Dizziness, fever, headache Alopecia, dermatitis, pruritus, rash Anorexia, dyspepsia, GERD, nausea Anemia aplastic anemia, hemolytic anemia (in G6PD deficiency), leukopenia Precipitation of acute gouty arthritis Rash, hypersensitivity, uric acid nephrolithiasis
119
Probenecid contraindication
``` Hx of urolithiasis overproducers of uric acid Hypersensitivity to probenecid Small or large dose salicylate therapy Blood dyscasias <2 yo Initiation during acute gout attack ```
120
Probenecid precautions
G5PD, PUD, renal impairment Methotrexate, penicillin, salicylates
121
Probenecid DDI
Salicylates Penicillins/cephalosporins/carbapenems Methotrexate Pegloticase
122
Probenecid monitoring
SUA | Renal fxn
123
Probenecid pt education pts
Increase fluid intake
124
Uricosurics examples
Probenecid (Benemid) | Losartan
125
Losartan gout dosing and place in therapy
No specific dosing for gout If pt has HTN, add on to XOI to pts not controlled on single agent
126
Probenecid place in therapy
XOI is preferred with CKD ≥3 | Can be ADD-ON
127
Pegloticase brand name
Krystexxa
128
Pegloticase MOA
pegylated recombinant modified mammalian urate oxidase (uricase)
129
Pegloticase is usually administered with __ and ___ as pre-medication
corticosteroid and antihistamine
130
Pegloticase ADEs
``` Gout flares Infusion reactions Nausea Vomiting Bruising Nasopharyngitis Constipation Chest pain Anaphylaxis ```
131
Pegloticase boxed warning
Anaphylaxis (usually within 2 hrs)
132
Pegloticase CI
G5PD deficiency
133
Pegloticase precautions
Anaphylaxis Infusion reactions (slow it down) Gout flares Congestive HF
134
Pegloticase DDI
No studies with other drugs have been done -- stop ALL other ULT when you initiate pegloticase
135
T/F: You can use pegloticase as monotherapy or dual add-on therapy
FLASE -- pegloticase is monotherapy ONLY, STOP all other ULT when you initiate pegloticase
136
Pegloticase monitoring
SUA levels, freq of gout flares SUA levels G6PD screening prior to initiation in high risk pt pops (AA and mediterranean ancestry) S/sx of anaphylaxis
137
Pegloticase pt education
ADEs (gout flares, nasopharyngitis, etc.) | S/sx of infusion rxn or anaphylaxis

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