Gout Flashcards
What is Gout?
- Inflammatory response toward an Increase in uric acid crystals in the Joints
- Hyperuriemia [>6.8mg/dL] & Symptomatic
What is the epidemiology of Gout?
- Genetics, Diets, Economic Factors
- 9.2 millon people have it
- increased age & obesity
- Men
What is the Pathophysiology of Gout?
Breif Description?
- Uric Acid is the last step of the degredation
- Humans lack uricase
- Elevated by Overproduction & Underexcreation
In Hyperuricemia, what are some of the Underexcreation and Overproduction?
Underexcreation: Dehydration, Insulin Resistance, Acute Alcohol Intake, MEDICATION
Overproduction: Enzymatic Abnormalites, Cytotoxic Medications, Excessive Dietary Intake of Purines, Chronic Alochol Use
What are some of the Medications that are able to cause Hyperuricemia & Gout?
- Thiazide, Ethanol, Ethambutol, Nicotinic Acid, Pyrazinamide, Cytotoxic Drugs, Low Dose Aspirin, Testosterone, Cyclosporine
What are some of the Risk Factors that are in Gout?
- Obesity, Elderly, Male, Post-Menupasual Women, Diet, CKD, Alcohol, Medications
What are some of the Clinical Presentations of Gout?
Presentation? Signs and Symptoms? Labs? Complications?
- Mono-arthritis main involving Podagra [Big Toe]
- Sxs: Fever, Pain, Redness, Swelling, Warmth
- Labs: Increased Uric Acid & ** Leukocytes**
- Complications: Kidney Stones, Tophi [Deforming Joints]
What does the differentail diagnoses mean for Gout?
- Can present as a lot
- Pseudogout, Rheumatoid, Septic Arthritis, Celluitis, Unrelated hyperuricemia…
What is the Diagnostic Criteria for Gout?
- Aspiration of Synoival Fluids
- Symptoms
- Imaging
Based from the European League Against Rheumatism [EULAR]
What is important to know about the Aspiration fo Synovial Fluids in Diagnostic Criteria in Gout?
- Definitive Diagnosis
- Looking for those crystals
What is important to know about the Symptoms for the Diagonstic Criteria in Gout?
- Monoarthicular of foot or ankle
- Previous Episodes
- Rapid Onset
- Male
- Hyperuricemia
What is important to know about Imaging in Diagnostic Criteria in Gout?
- X-ray for Crystals
- Ultrasound for Tophi
What is the Nonpharmacologic treatments for Acute Gout?
- Not too much for Acute Gout
- Maybe using a Local Ice Pack –> decrease inflammation
What are the Pharmacology Therapies that are used in Acute Gout?
- NSAIDs
- Colchicine
- Steroids
What is the MOA for NSIADS in Acute Gout?
- MOA: Inhibtion of COX 1/2; decreaseing Prostaglandins; decreaseing Inflammation
What are the NSAIDS that are used in Acute Gout?
Know Dosing!
- Indomethacan 50 mg TID
- Naproxen 750 mg; then 250 mg q8h
- Sulindac 200 mg BID
ALL used until flares resolve!!
What are some of the Side Effects for NSAIDS in Acute Gout?
- GI Effects, Kidney Injury, CV Effects, Bleeding, Fluid Retention, CNS Effects
What is the MOA and Typical Dosing for Colchicine in Acute Gout?
- MOA: Inhibits B-tubulin polymerization into mircotubules
- Day 1: 1.2 mg; then 0.6 mg 1h later & Day 2: 0.6 mg BID
What are some of the Side Effects of Colchicine in Acute Gout?
- N/V/D
- Rare: Mylosuppression and Neuromyopathy
In what way do we dose adjust for Renal, Hepatic and Interactions for Colchicine in Acute Gout?
- Renal: CrCl > 30 = NO ADJUSTMENT & CrCl < 30 = Wait 2 weeks to repeat
- Hepatic: Mild/Mod = NO ADJUSTEMENT & Severe - = Wait 2 weeks to repeat
- Interactions: 3A4 & PgP
What is the MOA for Steroids in Acute Gout?
- MOA: Decreased inflammation by suppressing Leukocytes
Considerations: TAPER, Limt Use, IA not for Joint Sepsis
What are some of the Steroids that are used in Acute Gout?
- Oral: Methyprednisolone or Prednisone
- IM: Triamcinolone Acetonide or Methylprednisolone
- IA: Triamcinolone Acetonide
What are the Side Effects for Steroids in Acute Gout?
- N/V/D, Incresaed BP, Insomia, Hyperglycemia, Edema…
LIke in RA, Lupus, IBD…
When there is an inadequate inital response to Acute Gout Therapy, what should be done?
- Switch Agents
- Add Agents [NO NSAIDS with Steroids]
What is the Nonpharmacologic Therapies for Chronic Gout?
- Weight Loss, Dash Diet, Avoid fats and sweets, Decrease Alcohol
What are the Medications that are used in Urate Lowering Therapy in Chronic Gout?
- Xanthine Oxidase Inhibitors [1st line]
- Uricosurics [2nd Line]
- Uricase Agents [3rd Line]
What is important to know about the Urate Lowering Therapy in Chornic Gout?
Who doesnt need? When to Start? How long & Monitoring?
- Who dosen’t need: 1st Attack WITHOUT risk factors
- When: NOW; when having flare
- How Long: ULT forever
- Monitoring: Uric Acids < 6 mg/dL
What is the MOA of the Xanthine Oxidase Inhibitors in Chronic Gout?
- MOA: Reduces uric acid by imparing the abiility of Xanthine Oxidase to convert Hypoxantine to Xanthine to Uric Acid
What are the two Xanthine Oxidase Inhibitors that are used in Chronic Gout?
- Allopuiniol 100mg daily; titrate up to 800 mg/day
- Febuxostat: 40 mg daily; titrate up to 80 mg/day
What are some of the Side Effects of Allopurinol in Chronic Gout?
- Rash
- Possible Fatal Hypersensitivity Reactions [Stevens-Johnsons Syndrome or Toxic Epidermal Nerolysis] –> Highest risk during first 3 months
What is something that you should test for before taking Allopurinol in Chronic Gout?
- HLA-B 5801: + will increase risk of SE
What are some important counseling points for Allopurinol in Chronic Gout?
- Drink plenty of Fluids
- Take medication even when NO SYMPTOMS
What are some of the Side Effects for Febuxostat in Chronic Gout?
- Liver Enzyme Elevations, N, Arthralgias, rash
- BLACK BOX: Cardio issues = DEATH
What is the MOA of the Uricosuric Drugs in Chronic Gout?
- MOA: Inhibiting post-secretory renal tubular reabsorption of uric acid
What are the two Uricosuric Drugs that are used in Chronic Gout?
- Probenecid 250 mg BID X 1-2w [Titrating up to 6 mg/dL uric acid]
- Lesinurad 200 mg once daily [ONLY taken with Xanthines]
What is important to know about Probenecid in Chronic Gout?
ADRs? Cautions? interactions?
- ADR: GI issues, Rash, Urolithiasis
- Caution: G6PD Deficiency, CKD Stage > 3
What is important to know about Lesinurad in Chronic Gout?
BLACK BOX? ADRs? Pearls?
- BLACK BOX: Nephrotoxicity; must be used WITH Allopurinol >300mg
- ADRs: Headache, GERD
- Pearls: 2C9
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What is the MOA of Uricase Agents in Chronic Gout?
- MOA: Helps make Uricase, which converts uric acid to the more soluble form Allantoin
What is the Uricase Agent that is used in Chronic Gout?
- Pegloticase 8 mg IV every 2w [2h long]
What is important to know about Pegloticase in Chronic Gout?
BLACK BOX? ADRs?
- BLACK BOX: Anaphylaxis & G6PD Deficiency
- ADR: GI issues, Chest Pain, Flu-Like symptoms
When should Pegloticase be used in Chronic Gout?
- When they are already on ULT + having Gout symptoms = ADD Pegloticase
What are some of the other ULT Medications that are used in Chornic Gout?
- Fenofibrate: Helps clear Uric Acid; For Gout + Increased Cholesterol
- Losartan: Inhibits reabsorption of uric acid; For Gout + HTN
How long should Gout Prophylaxis last?
- 3-6 months
What are some of the Prohylaxis options for Gout?
- NSAIDS
- Prednisone <10 mg/day
- Colchicine
For Gout Prophylaxis, what is important to understand about Colchicine dosing?
- Renal: CrCl > 30 = 0.6mg qd or BID; CrCl < 30 =0.3 mg daily
- Interactions 3A4 & PgP = 0.3 mg every other day to daily
