Gout Flashcards
(?) is a common form of inflammatory arthritis characterised by raised uric acid concentration in the blood and the deposition of urate crystals in joints and other tissues
Gout
Gout is a common form of inflammatory arthritis characterised by raised (?) concentration in the blood and the deposition of urate crystals in joints and other tissues
Uric acid
Gout is a common form of inflammatory arthritis characterised by raised uric acid concentration in the blood and the deposition of (?) crystals in joints and other tissues
Urate
What are the three distinct phases of gout?
- Asymptomatic hyperuricaemia
- A period of acute attacks followed by variable intervals (months to years) with no symptoms
- Chronic tophaceous gout, where people have nodules affecting joints
The management of gout in those under (?) years of age require specialist supervision
30
Which two drugs can you use to treat acute attacks of gout?
Colchicine
High doses of an NSAID (excluding aspirin)
If you prescribe a high dose of an NSAID to treat an acute attack of gout, what must you also prescribe?
A gastro-protective drug (e.g. PPI)
What is the limitation of colchicine in the management of acute attacks of gout?
Toxicity at higher doses
What is the advantage of colchicine in the management of acute attacks of gout? (2)
- Does not induce fluid retention (unlike NSAIDs)
2. Can be co-administered with anticoagulants
What should you do if acute attacks of gout has an inadequate response to monotherapy with either colchicine or high dose NSAIDs?
Combination therapy (colchicine + NSAIDs)
What procedure is an option for the management of an acute monoarticular gout attack?
Joint aspiration and intra-articular injection of a corticosteroid
In patients having an acute attack of gout who cannot tolerate NSAIDs or colchicine, and when an intra-articular injection is unsuitable, what are the two alternative treatment options?
- Short course of oral corticosteroids
2. Injection of IM corticosteroids
What is the definition of frequent gouty arthritis attacks?
At least 3 in the previous 12 months
What treatment option can be considered for frequent gouty arthritis attacks (at least 3 in the previous 12 months) in patients who have an inadequate response to standard treatment?
An interleukin-1 inhibitor (e.g. canakinumab)
Name two drugs used for the long-term control of gout?
Allopurinol
Febuxostat
Xanthine-oxidase inhibitors that reduce the formation of uric acid from purines
What is the mode of action of allopurinol and febuxostat?
Xanthine-oxidase inhibitors that reduce the formation of uric acid from purines
What is the first-line urate-lowering therapy for long-term control of gout?
Allopurinol
- Oral: initially 100 mg daily, adjust according to plasma uric acid concentration
- take after food
If allopurinol is contraindicated or not tolerated for the long-term control of gout, what is the alternative option?
Febuxostat
- Oral: initially 80 mg once daily, can be increased to 120 mg once daily
What type of drugs can be prescribed by a specialist in patients with gout who are resistant to or are intolerant of xanthine-oxidase inhibitor?
Uricosuric drugs
- Sulfinopyrazne
- Benzbromarone
Increase the excretion of uric acid in the urine
Can be combined with xanthine-oxidase inhibitors in patients who have an inadequate response to monotherapy
How do uricosuric drugs help in the management of long-term control of gout?
Increase the excretion of uric acid in the urine
Specialist use only
Can be combined with xanthine-oxidase inhibitors in patients who have an inadequate response to monotherapy
When do you start urate-lowering therapy in a patient who requires long-term control of gout?
After the inflammation in an acute attack has settled
Following an acute attack of gout, how long should colchicine be continued as prophylaxis in patients who will start urate-lowering therapy for long-term control of gout?
Up to 6 months
Colchicine is used as prophylaxis for up to 6 months as the initiation or up-titration of urate-lowering therapy may precipitate an acute attack of gout
Alternative to colchicine as prophylaxis: low-dose NSAID + gastro-protection
Do you stop urate-lowering therapy if an acute attack of gout occurs?
NO
Continue urate-lowering therapy at the same dosage, while treating the acute attack
What should you advise to patients with gout and a history of urolithiasis?
Ensure adequate daily fluid intake and avoid dehydration
(Acidization/Alkalinisation?) of the urine with potassium citrate can be considered in recurrent kidney stone formers
Alkalinisation
Alkalinisation of the urine with (?) can be considered in recurrent kidney stone formers
potassium citrate
Is allopurinol used during an acute attack of gout or for long-term control of gout?
Long-term control of gout
What is a common side effect of allopurinol?
Rash
Discontinue therapy if rash occurs.
If rash was mild re-introduce cautiously but discontinue immediately if recurrence
What do you do if a patient on allopurinol develops a rash?
Discontinue therapy if rash occurs.
If rash was mild re-introduce cautiously but discontinue immediately if recurrence
Can a pregnant patient take allopurinol?
ONLY if no safer alternative and disease carriers risk for mother or child
Toxicity not reported
Are dose adjustments of allopurinol required in hepatic or renal impairment?
Renal impairment
Max. initial dose 100 mg daily, increased only if response inadequate; in severe impairment, reduce daily dose below 100 mg, or increase dose interval; if facilities available, adjust dose to maintain plasma-oxipurinol concentration below 100 micromol/litre.
What is the mode of action of canakinumab?
A recombinant human monoclonal antibody that selectively inhibits interleukin-1 beta receptor binding
When would you consider using the interleukin-1 inhibitor, canakinumab, in the treatment of gout?
Acute attacks of gout in patients with frequent gouty arthritis attacks (at least 3 in the previous 12 months) in patients who have an inadequate response to standard treatment
Is colchicine used during an acute attack of gout or for long-term control of gout?
Acute attack of gout
Apart from acute gout, what is the other indication for the use of colchicine?
Prophylaxis of familial Mediterranean fever (recurrent polyserositis)
The dose of colchicine needs to be (?) if concurrent use of inhibitors of CYP3A4 or P-glycoprotein inhibitors
reduced
The dose of colchicine needs to be reduced if concurrent use of (?) of CYP3A4 or P-glycoprotein inhibitors
inhibitors
In elderly patients, when is a prescription of colchicine potentially inappropriate (STOPP criteria)?
- If eGFR less than 10 mL/miunute/1.73 m^2 (risk of toxicity)
- For chronic treatment of gout where there is no contraindication to a xanthine-oxidase inhibitor
Are dose adjustments of colchicine required in hepatic or renal impairment?
Renal impairment
Reduce dose or increase dosage interval if eGFR 10–50 mL/minute/1.73 m^2.
Avoid if eGFR less than 10 mL/minute/1.73 m^2.
Can colchicine be used during pregnancy?
NO
Teratogenicity in animal studies
What are the common side effects of colchicine? (4)
Abdominal pain
Diarrhoea
Nausea
Vomiting
Is febuxostat used during an acute attack of gout or for long-term control of gout?
Long-term control of gout
What are the common side effects of febuxostat?
- Diarrhoea
- Gout aggravated
- Headache
- Hepatic disorders
- Nausea
- Oedema
- Skin reactions
Are dose adjustments of febuxostat required in hepatic or renal impairment?
Hepatic impairment
Manufacturer advises max. 80 mg daily in mild impairment; no dose information available in moderate to severe impairment.
What needs to be monitored before and during treatment with febuxostat?
LFTs
