gout Flashcards
Epidemiology of gout
- inc age = inc risk
- inc in postmenopausal women due to estrogen loss
- link w/ co-morbid conditions, diet, med use, genetics
what conct is purine soluble and what is our goal UA level with therapy
soluble at <=6.7
goal w/ therapy 6.0 mg/dl
what causes overproduction of urate
- diet high in urate : red meat, seafood, beer, soft drinks, fructose
- disease states: DM, hyperlipidemia, obesity, CKD, HTN, Organ transplant, CHF
what diet is recommended for gout patients
coffee, diary vit c
What medications can be harmful to gout patients
- Thiazide diuretics
- Loop Diuretics
- Nicotinic Acid
- Aspirin <1g/day
Helpful Meds
Losartan (1st line), Fenofibrate
clinical presentation of gout flare
rapid onset (w/in 24 hours) of severe pain, erthyema & swelling in single or multiple joints
*ankle, fingers, wrist, elbows
What can cause a gout flare
alcohol ingestion
high purine ingestion
stress (emotional & physical)
Meds
3 ways to diagnosis gout and which is most common
- most common: gout flare
- crystals in synovial fluid
- Serum UA > 6.7
What agents can be used in acute gout flare
- Anti-inflammatory: NSAIDs, Colchicine
- Corticosteroids: Prednisone + Intra-articular triamcinolone
which NSAID has FDA approval for goat
Indomethicin, Sulindac, Naproxen
NSAID clinical pearls, avoid
- 1st line
- 7 day therapy
- Avoid in: renal impairment, bleeding disorders/anti coag, peptic ulcer disease, CHF, older adults>/= 75 age
*ppi for prophylaxis
Colchicine dosing acute vs prophylaxis
acute : 1.2 mg po x1 then .6mg 1 hr later
prophylaxis: 0.6 mg QDor BID
Strong CYP3A4 inhs and dose of colchicine (DICK)
Clarithromycin
Darunavir/Ritonavir
Itrazonazole
Ketoconazole
- acute: 0.6 mg x1 then .3mg 1 hr later
- prophylaxis: 0.3 mg every other day
Moderate CYP3A4 Inhibitors and dose of colchicine (VFED)
Dilitazem
Erythromycin
Fluconazole
Verapamil
- Acute: 1.2 mg x1
- prophylaxis: 0.3-0.6 mg QD
PGP inh and dose of colchicine (CAR)
Cyclosporine
Amiodarone
Ranolazine
- Acute: 0.6mg x1
- prophylaxis: 0.3mg every other day to 0.3mg once daily
Colchicine AE
Diarrhea
hematologic abnormalities
rnhabdomylosis (Risk w/ renal insuff elderly)
Intra-articular triamcinolone dosing and ae
- depends on joint size 40,30, 10
- ae: leukocytosis, inc appetite, mood changes, inc blood glucose
What agents can be used in chronic gout therapy
- Xanthine Oxidase: Allopurinol, Febuxostate
- Uricosurics: Probenicid
- Pegloticase
What is 1st line gout therapy
Allopurinol
Allopurinol dose SE and DDI
- 50-100 mg/day, dec in CKD <30
- se: rash
- DDI: Amoxicillin, Ampicillin, Thiazide, ACE-I cause cause inc rash
- DDI warfarin (dec allo dose)
- CI: 6-MP, Azathiopurine, Theophylline (D/C ALLO)
Febuxostate dose, ae, ci, avoid
- 40 mg QD inc to 80 mg until at target (inc q2 week)
- avoid w/ cardiac issues & crcl <30
- AE: HA, arthralgia, abdominal pain, n, LFTs, flushing
- CI: 6-MP, Azathiopurine, Theophylline
Probenicid dose, Avoid, DDI
- 250 mg BIDx 1 week, inc to 500 bid, maz 2g/day
- avoid in crcl <50 ml/min and nephrolithiasis
- DDI: Penicillin, Methotreaxate, Carbapenems, Salicylates
Pegloticase who gets it
LAST LINE
- Other therapies fail to achieve goal,
- pts w/ flares >/= 2yrs
- non-resolving tophi
Pegloticase BBW
Infusion related rxns & anaphylaxis
what do you premedicate Pegloticase with?
Anithistamines and corticosterioids
Who gets chronic therapy
- 1 or more tophi
- radiographic evidence of gout damage or
- 2 or more gout flares yearly
Who should we consider chronic therapy for
- hx of 1 or more attack but less 2 attacks per year
- ckd stage >/= 3, UA >9 mg/dl, urolithiasis
what to monitor in gout patients
UA levels monitored q2-5 wks with inc in therapy intensity until goal is reached
