Gout

Question 1

Pathophysiology

Answer 1

Complex arthritis
-Most common in males

Signs/Sx
-Painful inflammation in joints
-Tophi, kidney stones, urate nephropathy
-Fever, fatigue, leukocytosis

Question 2

Hyperuricemia

Answer 2

Normal 7 (males), 6 (premenopause females)

Increase in levels
-Crystallization, deposition in joints, triggers local inflammatory reaction

Normal level does not exclude gout
-Hyperuricemia ≠ Gout
-Increases risk of gout attacks

Question 3

Risk Factors

Answer 3

-Advancing age
-Male gender
-African American
-Family hx
-Metabolic syndrome
-Renal insufficiency
-Diabetes, HTN, HF
-Organ transplant

Question 4

Gout: Acute Initial Pharmacotherapy

Answer 4

Mono:
-NSAID
-Corticosteroid
-Colchicine

Combo:
-Colchicine + NSAID
-Colchicine + CS
-Colchicine + NSAID + CS

*if successful, then adjust uric acid lowering therapy

Question 5

NSAIDs

Answer 5

First line
-but caution in elderly, renal insufficiency, HF, PUD, anticoagulation, liver, asthma (REPHALA)

*celecoxib for acute disease in pts intolerant or CI to NSAIDs

Question 6

Corticosteroids

Answer 6

First line
-DOC if only 1-2 large joints involved
-Avoid if septic joint not excluded

Question 7

Colchicine

Answer 7

First line (NBN 70 SEC)
-Most effective in first 24 hours

-AE: NVD (serious: BMS, neuropathy in renal/liver and IV)

-DDIs: erythromycin, simvastatin, cyclosporine

-Reduce dose by 50% if 70+

1.2 mg PO then 0.6 mg 1 hr later

50+ 0.6 QD-BID
35-49: 0.6 QD
10-34: 0.6 2-3 d

Question 8

Mono vs Combo Therapy

Answer 8

Mono
-Mild/Mod, =< 6/10 for pain

Combo
-Severe, 7+ pain, polyarticular presentation

Question 9

First Line for Chronic Gout

Answer 9

Xanthin Oxidase
-Allopurinol or Febuxostat

Start during acute attack
*target urate <6, monitor 2-5 weeks

Question 10

Who should get chronic tx?

Answer 10

YES = Gout with tophi 1+, radiographic damage, or frequent flares >2/yr

Conditional = previous hx of infrequent flares, with urolithiasis/CKD3+/urate 9+

Question 11

Allopurinol

Answer 11

100 mg QD
-Increase by 100 every 2-5 weeks
-Lower for CKD3+
-Usual 200-600

*with prophylactic (NSAIDs/colchine) 3-6 mo

Screen for HLA B5801

Caution (GG HKH WAM)
-GI, rash, pruritus
-Precipitation of gout
-High LFTs
-Renal failure
-Hypersensitivity

DDI
-Aza, merca, warfarin

Question 12

Febuxostat

Answer 12

40 mg QD
-Up to 80 after 2-5 weeks

Caution in hepatic/renal (not studied)
-Consider not using in pts with new/hx of ASCVD event
-Initiation = more flares

AE: (CL RAN to the MAT STAT)
-High LFTs
-Nausea, rash
-Arthralgia
-Increase CVT events

CI:
-Aza, merca, theo

Also prophylactic tx (NSAIDs/colchicine) 3-6 mo

Question 13

Second line Tx: Uricosuric Agents

Answer 13

Intolerant to XOI or in combo for refractory hyperuricemia

-Probenacid
-Pegloticase
-Lesinurad

Question 14

Probenecid

Answer 14

U HAS been PRO 700
CI in urolithiasis
-Avoid in pts with 24h urine uric acid 700+

DDI
-Heparin, sal, abx

500 mg QD/BID (max 2000)

Question 15

Pegloticase

Answer 15

Refractory gout (treatment failure gout) = ongoing sx, cannot get < 6, bad QOL

8 mg IV Q2W
-premed with antihis and cs is required

Refrigerate, light protection

Cautions (Peggy got HAIRR thats an FF)
-Ana, infusion rxn (BBW)
-Gout flares
-Heart failure
-REMS

AE
-NV, constipation
-Chest pain
-Ecchymosis
-Nasopharyngitis

CI
-Hemolysis
-Methemoglob
-G6PD def

Question 16

Lesinurad

Answer 16

-Only in combo with XOI

200 mg/day
-AM with food/water at same time as XOI

Avoid CrCl < 45

BBW for renal failure if used w/o XOI

Question 17

Non-Pharmacology

Answer 17

-Rest
-Ice
-Triggers (cool temps, dehydration, trauma, surgery, etc)
-Diet, weight
-Smoking cessation
-Exercise

Question 18

Special Pops

Answer 18

1. AC/AP = nsaids
2. CHF = nsaids, cox
3. CKD/Liver = nsaids, cox, colchine
4. Dia/inf = cs
5. PUD = nsaids, cox, cs

Question 19

Drugs that cause HU

Answer 19

Thiazides
Levodopa
ASA
Niacin
Ethanol
Cyclo/Taco