Gout Flashcards
Goals of Thearpy for treating acute Gout Attacks
Goals
- terminate the acute attack
- prevent recurrent attacks
- prevent complications associated with the deposition of urate cyrstals in the tissues
First line Options for treating an acute gout attack
First Line Options
- NSAIDS (Naproxen & Indomethacin specifically: but all of them can work)
- Steroids (Prednisone)
- Clochicine
Determination of what pt. gets
- depend on specific pt. factors: cant take NSAIDS becuase of bad kidneys? or HF? etc.
- they’re all first line so they all will work
Acute Gout Attack : NSAIDS treatment
Monitoring what
Toxicity with these
how to help prevent a GI bleed in specific populations
NSAIDS
Efficacy
- look for resolution of symptoms (decreased swelling, redness and pain of the joint)
- look to prevent future attacks
Toxicitiy
- GI upset (take with food)
- GI Bleeding: less likely as this is a short course of NSAIDS
- Elevated BP : retains sodium
- edema: ^^
For those at an increased risk of a GI bleed (elderly, hx. of previous ucler, anticoag use & alcoholism) = consider adding in a PPI during the NSAID use to prevent
Who should NEVER use NSAIIDS: not even for this hsort course
- active PUD
- uncompestate HF
- reverly renally impaired
- hypersensitivity to asprin or other nsaids
non-pharm treatment of an acute gout
medication swaps
Non-Pharm
- rest joing for 1-2 days and apply ice
- weight loss
- increase fluids and stay hydrated
Dietary Changes
- limit alcohol (even 1-2/24 hours can impact)
- no high fructose corn syrup (desserts, jucies)
- decrease purine intake (ograns, beef, lamb, pork, sardine and shrimp
Medication Swaps
- hydrochorlthiazide and other thiazide diuertics & loops can make dehydration and gout worse = consider switching to ARB (losartan)
When is a urate-lowering medication indicated in individuals with gout
Strongly recommended in
- 1+ subcut. tophi
- radiographic evidence of damange due to gour
- frequent attacks more thatn 2 attacks a year
conditionally recommended
- 1+ gout flare, but infrequently occuring (< 2/year)
- those with CKD stage 3+ (bad kidneys risk of stone)
- serum urate > 9
- urolithiasis
Acute Gout Treatment: what if they cant take the first line medications
non-oral options = IV, IM or IA glucocoritcoid options (Srongest recommendation)
can use IL-1 inhibitors
- anakinra
- canakinumab
can use “medication in pocket” treatment where the pt. feels the symptoms coming on & has meds on had
Acute Gout Attack: Treatment of Colchicine
Efficacy
Toxicity
dosing peral
DD Interations at what CYP & Pglyp
Colchicine: an acute gout treatment
Dosing pearl
- works best when started immediately at the onset of symptoms
Efficacy
- resolution of symptoms (decrease swelling, redness and pain) & prevent of future attacks
Toxicity
- nausea
- vomiting
- diarrhea
DD Interactions
- CYP3A4: so induceers increase metabolism & ihibitors increase levels in body
- P-gylcoprotein: cyclosporines and ranolazine
CONTRAINDICATED do NOT uSe colchicine with strong CYP3A4 or P-glycoprotein inhibtors in renal impariemetn
ACute Gout Attack Treatment: prednisone
Oral Prednisone
- systemic corticosteroid
- dose then taper
can consider interarticualr steroid = good for 1-2 joint invovlement
When initiating Urate loweing therapy
what must be done before therapy
why
how long and until when
before initating urate lowering therapy (allopurinol) need to have them on a prophylatic anti-inflammatory
- because temporaitly while allopurinol and otehr urate lowering thearipires kick in = they increase the risk of a gouty attack
what can be used LOW DOSES
- prednisone
- NSAIDS
- colchicine
(the pt. will probably be on this already controling the acute attack at hand, so just continue it)
How Long
- at least 3-6 montsh after the ULT is initiated
the ULT can be started once treatment for the acute attack has begun, do not need to wait until the attack has resolved
ULT: for those with chronic or recurrent gout
Xanthine oxidase inhibitors (XOI) : Allopurinol
considerations
test for what
target treatment #
XOI: block the xanathine oxidaase: therefore block the breakdown the purines into uric acid
Names = Allopurinol
preferred agent: first line for everyone
Treat to Target: to the serum urate level want < 6
Considerations
- must test for the HLAB5801 gene in souteast asian decent and african american
- highest risk of SJS, TEN and eosinophilic and systemic dru reations with allopurinol
Dosing Goals
- doses < 300 but commonly need to go over that: just need to monitor as higher doses = higher risk of SE
Chronic/Recurrnt Gout Attacks: Treatment
XOI: Febuxostat
toxicities
BBW
who should use this
treat to target of what
XOI: Febuxostat
Who should use this
- those who cannot tolerate allopurinol
- those who are having inadequate responses to allopurinol
- those without CVD or new CV events
Toxicities
- rash
- nausea
- LFTs increased
- arthralias
BBW: increased risk of cardiovascualr death
Treat to Target: serum urate level ** < 6**
Second Line ULT medications
Probenecid: how does it work
Lesinurad: how does it work
Pegloticase: how does it work
Probencid
- inhibits reabosrbtion of uric acid at the proximal convoluted tubule = increases excretion
- therefore need good kidneys
- taken when: you cant take allopurinol OR in combo with for increased effects
- not able to be used if crcl < 50
- contraindicated in those with history of urolithiasis
Lesinurad
- inhibits resborbtion of uric acid by inhibiting URAT1 and OAT3 transporters = increase clearance
- need good kidneys
- NEEDS TO BE USED IN COMBO with allopurinol
- SE: HA, flu, increase SCr and GERD
- BBW: acute renal failure
Pegloticase
- recombinant of uricase which converts uric acid to allantoin; which is easily escreted
How to Change ULT
pegloticase specifics
when changing from one ULT to other:
- change to a new XOI
- add probenecid to XOI
- d/c OXi and start pegloticase for those with severe disease
Pegloticase
- for severe disease burden, d/c the XOI and start thise
- for those refractory or intolerate to XOi
- BBW: anaphylaxis and infusion rxn
- SCREEN FOR G6PD deficiency: hemolysis and methemoglobinemia
- IV every 2weeks
