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Advanced Pharma > Gout > Flashcards

Gout Flashcards

1
Q

gout is

A

an arthritis associated w/ the presence of monosodium urate crystals (MSU) in synovial fluid or tissue leading to inflammatory reactions that causes intense pain, erythema and joint swelling

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2
Q

hyperuricemia

A

serum uric acid >7.0 mg/dL in M
serum level >6.0 mg/dL in F

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3
Q

should you tx asymptomatic pt with elevated serum uric acid concentration?

A

no

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4
Q

hyperuricemia secondary causes

A
  • overproduction: purine rich diet, EToH, fructose, myeloproliferative disorders
    -underexecretion: ethanol, cyclosporine, thiazides, furosemide, ethambutol, pyrazinamide, levodopa, niacin, low dose ASA, CTX agents, CKR
    -wt, gender, HTN, etc.
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5
Q

non-pharm therapies

A
  • correction or modification of underlying factors - SEE secondary causes
    -meds, wt loss
    -reduce dietary intake of purine-rich foods
    -increase fluid intake
    -decrease salt consumption
    -joint rest/immobilization for 1-2d
    -application of ice to affected area
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6
Q

for attacks of mild/moderate gout severity

A

6 of 10 on a 0-10 pain VAS particularly those involving 1 or a few small joints or 1 or 2 large joints

…monotherapy

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7
Q

in the absence of comorbidities

A

NSAID > colchicine > corticosteroids

must consider pt specific factors & commorbidities

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8
Q

NSAIDs

A

most effective if started w/i 1st 24hr of onset and continued for 24hr after resolution

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9
Q

NSAIDs should be avoided

A

active PUD
uncompensated CHF
uncontrolled HTN
severe renal impairment (<30-35ml/min)

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10
Q

NSAIDs are effective when given at full anti-inflammatory doses except

A

ASA and Tolmetin

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11
Q

COXibs

A

unclear risk/benefit ratio in acute gout

-option in pts w/ GI contraindications or intolerance to NSAIDs

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12
Q

colchicine

A

possesses no analgesic or uric acid-lowering effects

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13
Q

colchicine: acute dosing

A

1.2mg initially, then 0.6mg 1h later
total: 1.8mg over 1hr

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14
Q

colchicine: acute dosing contraindication

A

renal and hepatic dysfunction
elderly
frail

in severe renal impairment (CrCl <30mL/min) should not be repeated for 14 days

CrCl 30-80mL/min: no renal adj necessary

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15
Q

colchicine: place in therapy

A

-NSAID intolerance
-pts at risk for NSAID-induced gastropathy (active PUD)
-moderate CKD (w/ proper dose modifications)
-failed NSAID therapy

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16
Q

colchicine: ARDs & CIs

A

mostly GI (alopecia, malabsorption of vit b12, myopathy, myelosuppression)

-severe renal/hepatic impairment (neutropenia
-severe renal/hepatic impairment
- concomitant use of P-glycoprotein (P-gp) or strong CYP3A4 inhibitor in presence of renal or hepatic impairment
-severe cardiac / GI disease

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17
Q

corticosteroids

A

indicated w/ NSAIDs or colchicine contraindication (eg. renal impairment)

or
tx failure

18
Q

corticosteroids: efficacy to NSAIDs

A

equally effective in acute gout tx

19
Q

corticosteroids: use

A

systemically (PO/IV/IM) or by intraarticular injection

slower tapering of the glucocorticoid dose w/ extension of the course 10-14 days or even 21 days

20
Q

corticosteroids: ARDS

A

-hyperglycemia
-HTN
-headache
-mood changes
-fluid retention

21
Q

corticosteroids: precautions

A

-DM
-uncontrolled HTN
-severe infections
-active PUD
-severe cardiovascular disease (HF)

22
Q

interleukin-1 (IL-1) inhibitors

A

anti-inflam agents in refractory gout or for pts who are unable to tolerate conventional therapy, such as NSAIDs, colchicine, or glucocorticoids, for acute attacks

***beneficial as 4th line therapy for acute gout due to their high cost and limited clinical experience

23
Q

corticotropin

A

exogenous administration of IM adrenocorticotropic hormone (ATCH) stimulates production of corticosterone by the adrenal cortex

40IU given IM and repeated q24h as needed

24
Q

combination therapy

A

in severe polyarticular attacks, particularly attacks involving multiple large joints

-colchicine may be used in combination w/ an NSAID or oral corticosteroid

-intraarticular corticosteroid injections may be used in combination w/ any other first0line agent (NSAID, colchicine, oral corticosteroid)

25
Q

prophylaxis

A

-two or more gout attacks per year
-tophaceous gout
-joint damage seen on a radiograph
-uric acid nephrolithiasis/chronic kidney disease stage 2 or worse

26
Q

prophylaxis: non-pharm

A

lose wt if obese
discon’t EToH
low-purine diets
dicon’t drugs
maintain hydration

27
Q

prophylaxis: when to start

A

-during an acute gout attack only if anti-inflam tx is also initiated bc sudden shifts in SUA levels from mobilization of tissue urate stores may precipitate or exacerbate gouty arthritis

or

after resolution (4-6 wk) of acute attack; may use colchicine or low dose NSAIDs prophylactically upon initiation until [serum UA] returns to normal or max of 3-6 months

28
Q

GIOP

A

most common secondary cause of OP and 3rd most common cause overall

29
Q

American College of Rheumatology (ACR) recommends

A

oral bisphosphonate therapy for all patients age 40 and over at moderate-high of fx receiving glucocorticoids (prednisone 2.5 mg or more daily or equivalent) for 3 months+

30
Q

xanthine oxidase inhibitors

A

allopurinol

-prevention & tx of gout associated w/ hyperuricemia

reduces the serum uric acid level while increasing the renal excretion of the more soluble oxypurine precursors

good for overproducers and underexcretors
1st-line therapy

31
Q

xanthine oxidase inhibitors: reserved for hypersensitive, intolerable or had failure w/ allopurinol

A

febuxostat

several clinically significant DI

32
Q

uricosurics

A

drug class

promote excretion of uric acid
eg. probenicic

best for underexcreators

33
Q

probenicid C/I

A

hypersensitivity reactions
renal dysfunction
hx of kidney stones
acute attack
overproducers of uric acid

may share allergenicity w/ other classes of sulfonamide drugs

34
Q

uric acid transporter 1 (URAT) and organic anion transporter 4 (OAT) inhibitor

A

Lesinurad

35
Q

American College of Rheumatology states that serum urate concentration in gout pts s/b reduced sufficiently to result in durable improvement in s&S of teh disease and recommends a target serum urate concentration of

A

<6 mg/dL (or <5mg/dL if nec to achieve such clinical improvements

-use in combination w/ xanthine oxidase inhibitor in pts who have no attained target serum uric acid concentratins
-do no use as monotherapy

36
Q

losartan

A

inc uric acid secretion and urinary pH

option for hypertensive pts w/ gout

37
Q

fibrates

A

increases uric acid secretion

option for select pts w/ hypertriglyceridemia

38
Q

colchicine

A

daily use (0.6-1.2mg/day) for prophylaxis
-renal dosage adj required w/ CrCl <30mL/min

39
Q

herbal treatments

A

no acceptable clinical evidence of efficacy or safety

40
Q

pegloticase

A

FDA-approved tx of chronic refractory gout

8mg IV q2w
start on prophylaxis w/ colchicine or NSAID when initiating therapy

41
Q

xanthine oxidase inhibitors: black box warning

A

must pretreat w/ antihistamines and corticosteroids

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