gout

Question 1

pathophysiology of gout

Answer 1

1. imbalances in purine metabolism
2. deposition of monosodium urate crystals in articular and periarticular tissues

Question 2

lifestyle risk factors

Answer 2

alcohol consumption
sugary beverages
red meat
sedentary lifestyle/obesity
males (gender narrows after menopause)

Question 3

drugs decreasing uric acid clearance

Answer 3

Diuretics (thiazides, loop diuretics)
Low dose salicylates
Ethambutol
Pyrazinamide
Levodopa

Question 4

diet induced purine/urate overproduction

Answer 4

excess ethanol, dietary purine, fructose, cytotoxic drugs

Question 5

examples of purine rich foods (name 3)

Answer 5

anchovies, asparagus, mushrooms, red meat, peanuts, durian, organ meat, cockles, mussels

Question 6

confirmatory diagnosis for gout

Answer 6

presence of uric acid crystals in joint aspirate

Question 7

treatment goals of gout

Answer 7

safe, effective pain relief
reduce future attacks
prevent joint destruction and tophi formation
increase qol

Question 8

avoid concurrent nsaids with…

Answer 8

steroids

Question 9

colchicine dosage for acute flare

Answer 9

1mg LD + 0.5mg 1hr later
or
0.5mg BD/TDS until acute flare resolves

Question 10

colchicine main AE

Answer 10

gi

Question 11

non pharm for gout

Answer 11

topical ice, max 15 mins, do not put directly over

Question 12

alternative to nsaids/colchicine

Answer 12

intra-articular/IM corticosteroids

Question 13

treatment target for non-tophaceous gout

Answer 13

< 360 µmol/L (6mg/dL)

Question 14

when to initiate ult

Answer 14

• at least two gout flares per year
• presence of tophus
• clinical or imaging findings of gouty arthropathy
• urolithiasis hx

Question 15

clinical remission means

Answer 15

no flares for ≥1 year and no tophi

Question 16

colchicine moa

Answer 16

Anti-mitotic;

Binds to tubulin, prevents polymerisation into microtubules

Inhibits leukocyte migration and phagocytosis

Inhibiting leukotriene B4 and PG production

Question 17

precautions of colchicine

Answer 17

renal impairment (especially when paired with NSAIDs)

Question 18

colchicine metabolism and common ddi

Answer 18

cyp3a4

statins, azoles, macrolides

Question 19

colchicine ci

Answer 19

crcl<30ml/min

Question 20

colchicine adverse reactions

Answer 20

GI (NVD), ab pain, muscle weakness, unusual bleeding

Question 21

allopurinol and febuxostat moa

Answer 21

Xanthine Oxidase inhibitors, prevent production of uric acid

Question 22

initiation dose of allo

Answer 22

maximum 100 mg/d

Question 23

how to titrate allo

Answer 23

50 to 100 mg every 2-8 weeks

Question 24

maintenance dose of allo

Answer 24

at least 300 mg/d

Question 25

what drugs with allo can increase bone marrow suppression?

Answer 25

6 mercaptopurine Azathioprine Cyclophosphamide

Question 26

what drugs with allo can increase toxicity of allo?

Answer 26

ACEi Loop/thiazides Ampicillin Amoxicillin

Question 27

allopurinol / febuxostat AE

Answer 27

Risk of SCAR (Allo>Feb) NVD, fever, sore throat, dark urine, jaundice Higher risk of death in patients with gout and major CVS (Feb>Allo)

Question 28

sjs ten symptoms

Answer 28

Fever, lesions leading to necrosis and sloughing of epidermis

Question 29

dress symptoms

Answer 29

Fever, rash, multiorgan failure

Question 30

gene involved with increased scar risk

Answer 30

hlab*-5801(Han Chinese, Thai, Korean)

Question 31

other clinically significant ddi

Answer 31

CBZ, Warfarin, Theophylline (increased concentration)

Question 32

initiation of ULT should be accompanied by? and what doses?

Answer 32

Anti-inflammatory prophylaxis for 3-6 months Colchicine 0.5mg OD PO Celecoxib 200 mg OD PO Prednisolone 5-7.5 mg OD

Question 33

febuxostat how to initiate

Answer 33

max 40mg/d

Question 34

titrate febuxo

Answer 34

up to 80mg/d if target not met after 2-4 weeks

Question 35

febuxostat metab

Answer 35

liver

Question 36

febuxo caution in

Answer 36

hf/chd

Question 37

probenecid moa

Answer 37

Uricosuric agents.URAT1 [& GLUT9 inhibitor. Inhibit proximal tubule anion transport and uric acid reabsorption.

Question 38

initiate probenecid

Answer 38

250mg BD x 1wk then 500mg BD

Question 39

titrate probenecid

Answer 39

500 mg/mth

Question 40

maintain probenecid

Answer 40

≤2 g/d

Question 41

probenecid ci

Answer 41

Urolithiasis CrCl <50ml/min (ESRF)

Question 42

probenecid ae

Answer 42

NV, painful urination, rash, lower back pain haemolytic anemia (pts with g6pd)

Question 43

probenecid admin instructions

Answer 43

hydrate at least 2L a day to prevent formation of kidney stones ensure urine pH >6 by administering alkaline

Question 44

are opioids preferred for gout/ra/oa

Answer 44

not anti-inflammatory

Question 45

opioids ae

Answer 45

gi (nv, constipation) hormonal effects depression respiratory effects overdose and death fractures sedation tolerance, addiction opioid-induced hyperalgesia

Question 46

precautions for opioids

Answer 46

cns depressants, renal/hepatic insufficiency, >65 yo, pregnancy, hx of substance use disorder