Gout

Question 1

gout is

Answer 1

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

Question 2

hyperuricemia

Answer 2

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

Question 3

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

Answer 3

no

Question 4

hyperuricemia secondary causes

Answer 4

• 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.

Question 5

non-pharm therapies

Answer 5

• 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

Question 6

for attacks of mild/moderate gout severity

Answer 6

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

Question 7

in the absence of comorbidities

Answer 7

NSAID > colchicine > corticosteroids

must consider pt specific factors & commorbidities

Question 8

NSAIDs

Answer 8

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

Question 9

NSAIDs should be avoided

Answer 9

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

Question 10

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

Answer 10

ASA and Tolmetin

Question 11

COXibs

Answer 11

unclear risk/benefit ratio in acute gout

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

Question 12

colchicine

Answer 12

possesses no analgesic or uric acid-lowering effects

Question 13

colchicine: acute dosing

Answer 13

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

Question 14

colchicine: acute dosing contraindication

Answer 14

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

Question 15

colchicine: place in therapy

Answer 15

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

Question 16

colchicine: ARDs & CIs

Answer 16

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

Question 17

corticosteroids

Answer 17

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

or
tx failure

Question 18

corticosteroids: efficacy to NSAIDs

Answer 18

equally effective in acute gout tx

Question 19

corticosteroids: use

Answer 19

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

Question 20

corticosteroids: ARDS

Answer 20

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

Question 21

corticosteroids: precautions

Answer 21

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

Question 22

interleukin-1 (IL-1) inhibitors

Answer 22

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

Question 23

corticotropin

Answer 23

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

40IU given IM and repeated q24h as needed

Question 24

combination therapy

Answer 24

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)

Question 25

prophylaxis

Answer 25

-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

Question 26

prophylaxis: non-pharm

Answer 26

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

Question 27

prophylaxis: when to start

Answer 27

-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

Question 28

GIOP

Answer 28

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

Question 29

American College of Rheumatology (ACR) recommends

Answer 29

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+

Question 30

xanthine oxidase inhibitors

Answer 30

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*

Question 31

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

Answer 31

febuxostat several clinically significant DI

Question 32

uricosurics

Answer 32

drug class promote excretion of uric acid eg. probenicic ***best for underexcreators***

Question 33

probenicid C/I

Answer 33

hypersensitivity reactions renal dysfunction hx of kidney stones acute attack overproducers of uric acid ***may share allergenicity w/ other classes of sulfonamide drugs***

Question 34

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

Answer 34

Lesinurad

Question 35

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

Answer 35

<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

Question 36

losartan

Answer 36

inc uric acid secretion and urinary pH ***option for hypertensive pts w/ gout***

Question 37

fibrates

Answer 37

increases uric acid secretion ***option for select pts w/ hypertriglyceridemia***

Question 38

colchicine

Answer 38

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

Question 39

herbal treatments

Answer 39

no acceptable clinical evidence of efficacy or safety

Question 40

pegloticase

Answer 40

FDA-approved tx of chronic refractory gout 8mg IV q2w start on prophylaxis w/ colchicine or NSAID when initiating therapy

Question 41

xanthine oxidase inhibitors: black box warning

Answer 41

must pretreat w/ antihistamines and corticosteroids