Gout

Question 1

First line meds for acute gout attack

Answer 1

NSAIDs, colchicine, oral corticosteroids - all first line anti-inflammatories, started within 24h, may combine for severe attacks

Question 2

Colchicine dose

Answer 2

dose: 1.2mg stat, 0.6mg in 1h, then after 12h start prophylaxis 0.6mg 1-2x/day
dose adjustment: half doses in >70yo, renal dysfxn, pgp inhibitor

Question 3

Colchicine AE, DDI, CI

Answer 3

AE: n/v/d/cramps (common at higher doses)
CI: renal or hepatic impairment + taking CYP3A4 or PGP inhibitor

Question 4

NSAIDs for gout

Answer 4

indomethacin or naproxen often used for prophylaxis
avoid celecoxib (cox2 selective) in hx of CVD
use non selective nsaid+ppi in age >65, previous GI bleed, anticoagulant, corticosteroid

Question 5

corticosteroids for gout

Answer 5

usually prednisone 0.5mg/kg/day for 5 days
Doses <20 mg/day may be
ineffective.

Question 6

long term prophylactic urate lowering therapy indications

Answer 6

if 2 or more gout attacks/y, established diagnosis with tophi, CKD stage 2, past urolithiasis
can be started during acute attacks if on antiinflammatory

Question 7

first line urate lowering tx

Answer 7

Xanthine Oxidase Inhibitors
Allopurinol & Febuxostat
MOA: inhibit uric acid production
AE: Allopurinol: rash (pts with mild rxns can be desensitized), hypersensitivity (SJS, TEN) - inc risk if starting at high doses, should use lower doses in renal dysfxn
AE: Febuxostat: n/d, arthralgia, rash

Question 8

alternative urate lowering tx

Answer 8

Uricosuric - Probenecid (special access program)
Off-label - fenofibrate, losartaan

Question 9

low purine diet

Answer 9

avoid organ meats, beef, lamb, pork, seafood, alcohol, table salt, table sugar, naturally sweet fruit juices, fructose, corn syrup

Question 10

some drug causes of hyperuricemia

Answer 10

diuretics, levodopa, tacrolimus…see CPS for more

Question 11

some medical conditions often associated with hyperuricemia

Answer 11

CKD, diabetes, HTN, obesity, alcoholism… see CPS for more

Question 12

nonpharm tx for gout

Answer 12

ice application during acute attacks
weight loss if obese
low purine diet

Question 13

colchicine should be started

Answer 13

acute attacks: start within 24h, not recommended starting if beyond 36h
the earlier therapy is started, the more quickly the attack will be resolved

Question 14

colchicine can be used for how long

Answer 14

can use for 3-6mths while initiating long term prophylactic urate lowering therapy which can precipitate attacks initially

Question 15

how long do patients have to be on urate lowering therapy

Answer 15

treat-to-target approach aims to lower serum urate at least to <360 µmol/L - checked every 6mths once stable
no evidence on best time to d/c
but some evidence suggesting CV benefit (lower MI risk)

Question 16

prophylaxis of acute attacks during initiation of urate lowering therapy

Answer 16

NSAIDs or colchicine 1st line
Prednisone 2nd line if above CI
Duration: at least 6 mths; if serum target reached and no tophi then 3 more mths, if target reached but tophi then 6 more mths