Gout

Question 1

Risk factors of gout

Answer 1

o MOHFO (Male, Obese, Hyper everything, Frequent Alcohol, Others)
o 30-50 year old Male
o Obese
o HTN
o Hyperlipidemia
o T2DM
o Frequent Alcohol intake (beer and spirits only, not Wine)
 Include purines (uric acid is made from broken down purines)
o Concurrent Illness (lymphoma/leukemia, Tumor Lysis Syndrome, any illness where they are on diuretics)
o Concurrent Drugs (any drugs that would decrease excretion (diuretics), Cytotoxins, cyclosporine (transplants, usually on diuretics), niacin, pyrazinamide, low-dose aspirin

Question 2

Acute Gout treatment: NSAIDS

Answer 2

First-line treatment (sulindac, naproxen, and indomethacin)
Indomethacin is associated with more gastropathy than other NSAIDs and should be avoided
Cox-2 inhibitors are also effective, but rarely used due to safety concerns and cost

Question 3

Gout Patients to avoid NSAID use in

Answer 3

PUD
GI bleed
Warfarin use
Acute/chronic kidney dysfunction

Question 4

Acute Gout treatment: Colchicine

Answer 4

use in patients with NSAID grastropathy or failed NSAID therapy
Must be used as soon as possible after symptoms detected
can be used long-term for prophylaxis and as adjunctive therapy to long-term chronic therapy
Dose-adjustments for renal dysfunction (decrease by 50% if CrCl <50)

Question 5

Colchicine CIs

Answer 5

Macrolides!!!!!!

Also diltiazem/verapamil

Question 6

Colchicine ADRs

Answer 6

N/V/D (diarrhea is limiting effect)
Abdominal pain
Neutropenia
Rhabdomyolysis

Question 7

Acute Gout treatment: Corticosteroids

Answer 7

Can be used as an injection straight into joints (triamcinolone)
Or systemically if patient has NSAID gastropathy, PUD, renal insufficiency (prednisone taper)
Monitor blood glucose in diabetic patients

Question 8

Chronic gout treatment: allopurinol

Answer 8

first-line. used in overproducers and underexcreters
used with or with-out colchicine for 6 months
can be used if CrCl <50 and history of renal calculi or renal dysfunction
Increases liklihood of ampicillin-induced rash
alcohol decreases effectiveness
Not CI with NSAIDs

Question 9

Allopurinol dosing

Answer 9

Based on CrCl
>90 = 300mg/day
60-90 = 200
30-60 = 100
<30 = 50
Max of 800mg/day

Question 10

Allopurinol ADRs

Answer 10

N/V/D
Rash
Increased LFTs
Leukopenia
Thrombocytopenia
Drug fever

Question 11

Allopurinol CIs

Answer 11

6MP
AZA
Cyclophosphamide
High-dose Vit C

Question 12

Chronic Gout Treatment: Probenicid

Answer 12

Used only for underexcreters
not widely used in US
may be used with or without low-dose colchicine for 6 months
Only used when a pt has CI to allopurinol
Make sure the patient stays hydrated (2-3L water daily)
Less effective in pts with CrCl <30
Chosen more often in interval gout

Question 13

Probenicid ADRs

Answer 13

GI
Rash
Hypersensitivity
Stone formation

Question 14

Probenicid CIs

Answer 14

prior nephrolithiasis, rarely effective for tophi
CrCl <50
Overproducers
renal calculi

Question 15

Chronic Gout Treatment: Febuxostat

Answer 15

newer xanthine oxidase inhibitor (like allopurinol)
not cleared renally (safe for CKD)
more likely to reach SUA target, but has more flares initially
can be used in allopurinol hypersensitivity syndrome
more expensive than other options

Question 16

Effective Adjunctive Agents to SUA lowering therapy

Answer 16

Losartan (Only ARB/ACE-I proven to lower SUA)
Fenofibrate
both lower SUA ~20%

Question 17

What is allopurinol hypersensitivity syndrome?

Answer 17

too rapid increase in allopurinol dose leads to escalation of hypersensitivity rxn
rare, but has 20% mortality rate
More common in Korean or Han Chinese patients (genomic testing to predict)
Monitor each new dose closely in first 4 weeks

Question 18

Allopurinol Hypersensitivity Syndrome AEs

Answer 18

Fever
Eosinophilia
rash/desquamating lesions
hepatid cysfunction 
(FERH)