gout Flashcards by Keri Courtnage

gout is a result of ___

overproduction and underexcretion of uric acid

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the enzyme that converts purines to uric acid

xanthine oxidase

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non modifiable risk factors gout

male, elderly, living in developed countries, genetics

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modifiable risk factors gout

diet high in purine (red meat, organ meat, shrimp)
high fructose corn syrup
alcohol (beer, wine)
medications
obesity
HTN, HLD, CKD

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what drug INCREASES uric acid excretion

losartan

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what drugs cause UNDEREXCRETION of uric acid

low dose ASA
thiazide and loop diuretics
levodopa
tacrolimus and cyclosporine

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what, other than drugs, causes underexcretion of uric acid

renal impairment, HTN, alcohol, dehydration

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what causes overproduction of uric acid

diet, cytotoxic medications, psoriasis, sickle cell disease, lympho/myeloproliferative diseases

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what is the gold standard for gout diagnosis

aspiration of synovial fluid or tophi

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serum uric acid > __ is gout

6.5-6.8 mg/dL

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when is the best time to check serum uric acid

2 weeks after a flare

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clinical presentation gout

usually presents as an acute flare; intense joint pain that comes on suddenly/middle of night; joints are swollen, painful, red, warm to touch

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____ is a sign of chronic gout

tophi

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what are the 4 stages of gout

-asymptomatic
-acute gouty arthritis
-inter critical gout
-chronic recurrent gout

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what are the points of asymptomatic gout

serum uric acid levels are >6.8 but no history of gouty attack

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does asymptomatic gout warrant treatment

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what is inter critical gout

the asymptomatic period between attacks

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what characterizes chronic recurrent gount

the presence of tophi, persistent joint stiffness and inflammation, radiographic erosions

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complications of gout

joint damage and deformity
kidney stones
kidney disease/failure
psychological and emotional problems

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goal serum uric acid level

<6 mg/dL

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initiate pharmacological therapy within __ hours of an acute gout attack

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first line agents for acute gout attack

NSAIDs, colchicine, steroids

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true or false: you should stop established urate lowering therapy during an acute gout attack

false

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which NSAIDs are rec in acute gout attack

sulindac
indomethacin
naproxen

box warning NSAIDs

increase risk of CV thrombotic events including MI/stroke

___ doses of NSAIDs are needed for gout to treat inflammation and pain

higher

naproxen dose

500 BID

indomethacin dose

50 TID

sulindac dose

200 BID

colchicine mech

interferes w/ migration of neutrophils to sites of inflammation that have been induced by deposits of urate crystals in synovial fluid

colchicine dosing regimen

1.2 mg initially followed by 0.6 mg one hour later 0.6 mg BID until flare resolves

adverse effects of colchicine

n/v/d, abdominal pain, muscle pain/weakness

drug interactions colchicine

CYP3A4 inhibitors and p-glycoprotein inhibitors

disease interactions colchicine

severe hepatic impairment or CrCL<30 + dialysis

prednisone dose

30-40 mg/d until resolution then taper 5 mg each day for 7-10d

intraarticular steroid for gout

triamcinolone 10, 30 or 40 mg IM triamcinolone 60 mg followed by PO corticosteroid if multiple joints

when is chronic urate lowering therapy indicated

1 or more subcutaneous tophi 2 or more attacks per year evidence of radiographic damage

first line urate lowering therapy

allopurinol

alternative XOI

febuxostat

alternative to XOI

probenicid

add on therapy

lesinurad

allopurinol dosing

start 100 mg/day (50 if CrCL<60) increase by 50-100 every 4 weeks (max 800)

what to tell the patient when starting XOI

acute gout flares during initiation

monitoring for allopurinol

rash, diarrhea, nausea, LFTs, neutropenia

allopurinol hypersensitivity syndrome

TEN and SJS concern

febuxostat dosing

40 mg daily if uric acid still >6 mg/dL after 2 weeks, increase to 80 mg daily

cautions with febuxostat

ischemic heart disease or CHF

allopurinol and febuxostat can precipitate a ___

gout attack

when starting XOI, you should

add one of the following: colchicine low dose NSAID low dose glucocorticoid

probenecid mechanism

inhibits tubular urate reabsorption in kidneys

probenecid dosing

250 mg po bid increase every 4 weeks up to max 1000 mg BID until goal urate

counseling probenecid

increase fluid intake to prevent kidney stones

probenecid contraindications

history of urolithiasis (can increase kidney stones) CrCL<50

lesinurad main point

must be used in combo with a XOI

lesinurad mech

inhibits the function of renal apical transporters that facilitate reabsorption of uric acid

lesinurad dosing

200 mg daily with food, water, XOI

last line agent gout

pegloticase

pegloticase when to use

if goal of SU<6 is not achieved, d/c the other therapies. only if gout dx burden is severe and refractory/intolerant to other options

pegloticase dosing

8 mg IV q2 weeks