Gout

Question 1

What causes gout?

Answer 1

Abnormally high uric acid levels, which deposits urate crystals in joints, soft tissue and urinary tract

Question 2

How can one obtain high levels of uric acid (hyperuricaemia)?

Answer 2

Overproduction of uric acid
Renal under excretion of uric acid
Both of the above
Overtaking high amounts of food rich in purines

Question 3

Which 2 drugs should NEVER be given with a condition like gout?

Answer 3

Aspirin - can cause uric acid retention
Thiazide-like diuretic - makes you return uric acid/glucose

Question 4

Which disease goes hand in hand with gout?

Answer 4

CVD

Question 5

What are some examples of foods/liquids that have high purine content?

Answer 5

All alcohol
Fish/seafood/shellfish
Organ meats
Turkey, bacon, other meats

Question 6

What are the symptoms of an acute attack of gout?

Answer 6

Pain
Redness/hotness of toe joints
Can cause fever
Night/early hour waking

Question 7

What is tophaceous gout?

Answer 7

Crystals of uric acid accumulating in the joints, forming yellow bumps/raises

Question 8

What must you avoid while treating an acute attack of gout?

Answer 8

Fluctuating uric acid levels, as this can prolong the attack or trigger future ones.

Question 9

What are the 4 treatment options for an acute attack of gout?

Answer 9

NSAIDs
Colchicine
Steroids
Monoclonal antibodies

Question 10

Which NSAID is the safest to use for an acute attack of gout, and why?

Answer 10

Naproxen because it has the best CV safety profile
Can also use: ketoprofen, indometacin, diclofenac

Question 11

How is ibuprofen give for an acute attack of gout?

Answer 11

Off-licensed, so try to avoid.

Question 12

How long are NSAIDs usually required for, for an acute attack of gout?

Answer 12

7-14 days until the attack goes away

Question 13

Why is colchicine less effective than NSAIDs?

Answer 13

Because it has a slow onset of action, more side effects, and its efficacy is reduced over time

Question 14

What is the dosing of colchicine for an acute attack of gout?

Answer 14

Start ASAP due to reduced efficacy
1g, then 500mcg every 4h for 3 days

Question 15

What is the max dose of colchicine per day?

Answer 15

6mg

Question 16

If renal insufficiency is present, which class of drug is given for an acute attack of gout?

Answer 16

Steroids

Question 17

How are corticosteroids given for an acute gout attack, & why is this way preferred?

Answer 17

Given via injection into the affected joint to minimise side effects which can arise if taken orally

Question 18

Which corticosteroid is given for an acute gout attack?

Answer 18

Methyl prednisolone

Question 19

Which monoclonal antibody can be used for acute attacks if all treatment has not worked?

Answer 19

Canakinumab

Question 20

What lifestyle modifications can be done to help prevent future gout attacks?

Answer 20

Weight loss
Decrease alcohol
Reduce dietary purine intake
Increase water intake - to flush out the uric acid
Give basic drug e.g. Na+ bicarbonate which can ionise the uric acid

Question 21

What determines after an acute gout attack whether the patient should start reducing their uric acid levels?

Answer 21

If they have had >3 attacks + raised urate levels
Evidence of joint damage
Tophaceous deposits visible
Evidence of renal failure
Family history present
Normal rate levels cannot be achieved through lifestyle changes

Question 22

What is given as prophylaxis along with the long term drugs for gout, & for how long?

Answer 22

NSAIDs/colchicine for 3 months (at low doses), until uric acid levels are stable

Question 23

What type of drug is allopurinol, & what is its mechanism of action?

Answer 23

It is a xanthine oxidase inhibitor preventing uric acid formation from purines

Question 24

When can you not start allopurinol? When should you start it?

Answer 24

It should never be started during an acute attack.
Must start 1-2 weeks after acute attack has subsided

Question 25

What is the dosing for allopurinol?

Answer 25

100mg OD
Max 900mg

Question 26

Why should plenty of water be taken while using allopurinol?

Answer 26

To flush out its metabolites from the kidneys

Question 27

Why can allopurinol be given to renally impaired patients?

Answer 27

Because allopurinol itself does not work on the kidneys

Question 28

What should you do if a patient taking allopurinol develops a rash?

Answer 28

Discontinue allopurinol and refer
This is a sign of a severe skin condition

Question 29

What type of drug is febuxostat?

Answer 29

It is a xanthine oxidase inhibitor

Question 30

Why is allopurinol used over febuxostat?

Answer 30

Because febuxostat has increased risk of CVD and GI side effects.

Question 31

Why should plenty of water be taken while using febuxostat?

Answer 31

To remove/flush out the accumulation of uric acid crystals in the kidneys

Question 32

Can you give febuxostat to renally impaired patients?

Answer 32

No

Question 33

Why is febuxostat preferred to be taken with milk?

Answer 33

Because milk is alkaline which can remove accumulated uric acid crystals

Question 34

What is the dosing of febuxostat?

Answer 34

80mg OD

Question 35

What type of drug is sulfinpyrazone, and how does it work?

Answer 35

It is a uricosuric which increases urine excretion by blocking tubular reabsorption of urate

Question 36

In which patients is sulfinpyrazone contraindicated in?

Answer 36

Renally impaired patients
Those with a history of uric acid stones in their kidneys

Question 37

When should you start sulfinpyrazones after an acute gout attack?

Answer 37

Given 3 weeks after an acute attack

Question 38

Why is drinking plenty of fluids essential when taking sulfinpyrazone?

Answer 38

Because the risk of urate crystal formation is high in renal tubes, so they need to be flushed out.

Question 39

What is the dosing of sulfinpyrazone?

Answer 39

Titrated up to 600mg, then reduced to maintenance dose of 200mg when uric acid levels stabilise