Gout Flashcards
what are the treatment guidelines for an acute gouty attack?
monotherapy with:
1. NSAIDs
2. low dose colchicine
3. corticosteroids
if pain does not resolve:
- combo therapy (NSAIDS, low dose colchine)
if pain does not resolve:
- interleukin inhibitors (not often)
adjuncts: ice
when to start pharmacotherapy for an acute gouty attack?
- initiate therapy within 24 hours
- ongoing urate lowering therapy should not be interrupted during acute treatment
when is combination therapy for an acute gouty attack used?
if failed monotherapy
what are acceptable combination therapy for an acute gouty attack?
- Colchicine and NSAID
- Oral corticosteroids and colchicine
- Intraarticular steroids with all other modalities
we should not used NSAIDs and systemic corticosteroids in combination. why?
similar MOA, will not increase the effect
increasing side effects
which NSAIDs to use for an acute gouty attack?
all are considered effective when given at an anti-inflammatory dose
- stop after 2-3 days after clinical signs ends
what is the most used NSAID for an acute gouty attack?
indomethacin
- lots of SEs: CNS, GI bleed
when is colchicine recommended?
within 36 hours of gouty attack onset
when to adjust the dose for colchicine?
- renal insufficiency
- hepatic insufficiency
- use with caution or strong CYP 34A inhibitors
what are adverse effects of colchicine?
- GI effects (N/V/D, abdominal pain)
- Bone marrow suppression
- Myotoxicity (including rhabdomyolysis)
when is colchicine CI?
- CrCl < 10ml/min
- Neutropenia
- Treatment of gout flare with colchicine is not recommended in patients receiving prophylactic colchicine and CYP3A4 inhibitors
what is the dose of corticosteroids for gout?
Oral: prednisone 0.5mg/kg/day for 5 days
- might not need to taper
when are corticosteroids used for gout?
Typically reserved for patients who do not tolerate or have CI to colchicine or NSAIDs
what are long term adverse effects of corticosteroids?
- HPA suppression
- OP
- Cataracts
- Muscle deconditioning
why are interleukin 1 inhibitors used for gout?
reduces infalmmation associated with gout
- off-label use
What are the different interleukin 1 inhibitors
- Anakinra
- Canakinumab
*used if combo therapy doesnt work
when is long-term urate lowering therapy used for gout?
Any patient with established diagnosis of gouty arthritis AND one or more of the following:
- Tophus or tophi by clinical exam or imaging study
- Frequent attacks of acute gouty arthritis (≥2 attacks/yr)
- CKD stage 2 or worse
- Past urolithiasis
what are the treatment guidelines for urate lowering therapy?
- allopurinol
- if allopurinol in CI –> febuxostat (both XOI) - febuxostat
- probenecid with XOI
- pegloticase if 1, 2, and 3 do not work
what is the dose of allopurinol?
Starting dosage should be no greater than 100 mg/day for any patient
- Start at 50 mg/day with CrCl <60ml/min
- with renal impairment: monitor for toxicity
what are the SEs of allopurinol?
- Nausea
- Diarrhea
- Rash (rare, can lead to Stevens-Johnson syndrome)
- Bone marrow suppression
- Allopurinol hypersensitivity syndrome (AHS)
what drug can be used if there is a hypersensitivity to allopurinol?
febuxostat
What are the Xanthine oxide inhibitors
- Allopurinol
- Febuostat
What are the uricosuric therapy meds
- Probenecid
- Lesinurad
When is Pegloticase used
- In patient with severe gout disease burden and refractory to or an intolerance to oral ULT options
what is the disadvantage of pegloticase?
expensive! $32,000 per dose
What are the ADRs of Pegloticase
- Infusion reactions
when is prophylactic anti-inflammatory therapy recommended?
for all case scenarios of gout when ULT is initiated
- crystals shift inside joints and might cause pain
what are the drugs recommended for prophylactic anti-inflammatory therapy?
- Colchicine 0.6mg BID
- Low-dose NSAIDs (e.g. naproxen 250mg BID)
- Low-dose prednisone or prednisolone (<10mg daily)
what is long-term management for gout?
- gout prophylaxis
- monitor serum urate and ULT
- urate levels under 6 mg
- look for causes: meds, obesity, cancer, alcohol
how to treat kidney stones that develop as a result of gout?
- hydration (2 to 3L)
- alkalize urine: potassium citrate or potassium bicarbonate
- acetazolamide (250)
