Gout Flashcards
Is gout an inflammatory or noninflammatory disorder?
inflammatory
what is the main cause of gout?
hyperurecimeia
what concentrations of uric acid are indicative of gout in men and females?
416 mew mol for men
357 mew mol for women
does elevated uric acid levels always lead to gout?
we can have asymptomatic gout!
what are some risk factors for gout?
- men (3 times as common)
- 40 (for men) and 60 (for females)
- sedentary lifestyle, obesity
- food high in purines (alchol)
what stage of purine degradation is uric acid?
the final stage
talk about limits of solubility
normal serum uric acid level are already at the limit of solubility so it takes very little to shift this balance
hyperurcemia is the cause of what?
over production or underextrection of uric acid (under excration is most commonly the cause)
discuss what can lead to over production?
- cell death (cells have a lot of uric acid in them) - meds used to treat blood cancer cause cell death
can diet cause over production?
rarely
what are the two types of drugs that affect uric acid production?
- xanthine oxidase inhibitors (allopurinol, and febuxostat)
- renal reabsorption
discuss what can lead to under execration?
- dehydration - we retain Na and therefore we also retain uric acid
- drugs can affect it ( thiazide diruretics)
how much uric acod is excreted through the renal system?
2/3
do we know why underexcretion of gout patients ahppnes?
not always - 90% unknown but as mentioned
dehydration and drugs can affect the excretion
what are the 4 clinical spectrums of the disease?
- asymtomatic
- gouty flare
- prophylaxis of flares
- chronic gouty arthitis (crystals formed in joints)
what is the treament for asymtopmatic gout?
non-phram
- no meds
- lifestyle changes (exercise, food less high in purines)
- identify drugs that may be leading to disccus and discuss changing them
what is the treament for a gout flare? what drugs can we use?
- treat within 24 hours
- NSAIDS
- Colchinie
- Oral steroids
what two drugs for treament of flares can never be combine?
NSAIDS and Oral steroids ( could cause toxicity)
monotherapy or two agents? also what are the options
try one agent but we can add another if needed
NSAID + colchinie
Colchine and oral steroid
IA steroid or NSAIS + colchine
what are the signs of a gout flare?
excruatiating pain, inflammation, sweeling
- fever elevated wbc
is it monarticular or biartiuclar?
monoarticular usualy
where does it often happen?
big toes, ankle, heel, knees, wrist, fingers, elbow (rarely)
distinguish between a presumptive diagnosis and a definitive diagnosis
presumptive - lab work (high uric acid), pain, inflammation of the big toe
definitive - take sample of synovial fluid and chvcek for presence of cystrals
when is combo therpay indicated?
severe gout >7 on pain scale
NSAID used? monitoring ? dosing?
indomethacin (has CNS SE) , if pain doesn’t get better in 7 days see a doc , dosing (loading dose so big amount to start then titrate down)
When should we start colchine?
within 36 hours - can give patient a PRN supple if they ahve repesetd gout attacks
What special consideration should we take when dosing elderly and those who are renally impaired with colchine?
reduce dose
what are some side effects common and rare of colchine?
common (in high doses) - abdominal pain and cramps, diarrhea, nausea and vomiting
Rare: neuropathy, myopathy, bone marrow suppression (a worry for those with renal insifficney)
Drug interactions for colchicine
- Statins level may increase so monitor for myotoxicity (muscle weakness, pain)
- If taking knonw CYP 3A4 inhibotrs, decrease dose and moniot for fever, leukopenia, GI symptoms) - these could be clarithyrmycin, - azonles
what is an important counseling point for colchine
avoid graphfruit
Oral or IA corticosteroid use?
Both
when is oral vs IA corticosteroid use indicated?
oral when more than two joints are affected
IA when 1-2 joints are involved and they must be big joints
what is the dosing for oral corticosteroids like?
prednisone - large dose to start off for 5 to 10 days, if used for less then 10- days no need for titrating down before discontinuing BUT beware that rebound attacks may occur
what are the two goal styles for prophylaxis therapy?
treat to target - less then 300 mew mol SUA, 360 for those with severe gout
treat to manage symptoms
when is uric lowering therapy indicated?
-when more then 2 gout attacks per year
- presence of uric acid stones
- presence of calcifcation tophi, tophus
- reduced kidney fucntion less then 90 mL/min
what does ULt therpay look like?
- start ULt therpay with allopurinol or febuxostat
- start low dose NSAID or colchine for 3-6 months after initiation ULT
does ULT risk or decrease risk for gout attacks
can increease thus we need NSAID and colchine for first 3-6 months
what is first line for ULT
allopurinol
what risk factors should we be cautious of in allopurinol use?
- elderly
- hepatic impariment
- renal impairment
- CKD
common side effects of Allopurinol?
Gi upset
can preciptate gout attack
serious side effects of allopuirnol
IF YOU DEVELOP A RASH OR ITCH STOP DRUG USE AND SEE HCP
- Steven johnson syndrom
- ten
- DRESS
how should we dose allopurinol? and moniotr
start low and go slow - can increase every 2-4 weeks
chcek lab values for SUA and renal function
what dose of allopurinol is usually needed to be effective?
300 mg/day
when is febuxostat/uloric indicated?
when we fail allopurinal or there is severe renal impriament
what are some drug interaction with allopurinol to note?
Azathipine and mercaptopurine - thiopruity toxicity - bone marrow suppression
Why is febuxostat indicated for renal insuffeincy?
very little is excreted renally
what has more flares during initiation, allopurinol or febuxostat?
febuxostat
drug interactions with febuxostat
azathioprine and mercaptopurine (CI)
Theophyline?
AE of febuxostat
- abnorlmities in LFTS
- Gi upset
- may increase cv risk
what is the moniotring for both phrophylauxs agents
2-4 weeks chcek SUA and increase dose, chcke renal function as well
3-6 once target reached
LFTS- if taking febuxostat
if renally impaired (crcl less then 90ml/min) what do we do for acute and prophylaxis therpay?
acute
-colchicine or steroids
- avoid NSAIDs
Prophylactic
- febuxostat
- allopurinol - with a dose adjustment
if CV comordbidities what do we do for acute and prophylaxis therapy?
acute:
- colchicine
- avoid NSAIDS and steroids for those in heart fialure
Prophylactic
- allopurinol
- febuxostat avoid
