Gout Flashcards
GOUT
Serum urate level > 8
Goal <6
Urate lowering agent: probenecid, allopurinol, febuxostat, lesiurad, pegloticase
For acute gouty attack : NSAIDS, colchicine, steroids
NSAIDS
Start 12 to 48 hours of ACUTE ATTACK
Indomethacin: Oral or rectal 50 mg TID-
Naproxen 250 mg TID until attack subsides
Suldinac 200 mg BID x 7 days ( max 400 mg /d )
Avoid:
Renal insufficiency ( CrCl < 60 )
Peptic ulcers
HF or HTN
Hyperkalemia
Indomethacin
50 mg q8 h for 3- 4 days then gradually taper off over 1 to 2 weeks’
Colchicine
MOA: inhibits cell division ( tells you it’s affecting bone marrow suppression like a chemo agent )
DOSE: oral for ACCUTE ATTACK gouty arthritis ( gout flare )
- 2 tabs ( 0.6 mg ), THEN 1 tab 1 hour later ( total 3 tabs = max 1.8 mg / 24 hours ) Colcrys
Prophylaxis in beginning : added in beginning ( while adding antihyperurecmeic agents to avoid risk of acute flare )
0.6 qod, qd,. Max is 0.6 bid
NEVER Give IV: Death
Colcrys is a 3a4 substrate
T Watching for DDI
INHIBITORS : will increase colchicine ( 169 deaths associated ) toxicity
Grapefruit juice
A : flu, keto , pos, voriconazole
P- Ritonavir , darunavir, atazanavir
C : clarithromycin, erythromycin ( CCB: diltiazem , verapamil )
Colchicine SE’s
GI : severe diarrhea
BMS: agranulocytosis, aplastic anemia and thrombocytopenia
Loss of body and scalp hair
Renal : contraindicated with dz :
Hepatic
Malabsorption syndrome: decreases vitamin B12 level ( may need to supplement ) , fats
Monitor during colchicine
CBC : if you get unusual bleeding, body aches, severe diarrhea, vomiting, contact MD
RENAL
HEPATIC
Corticosteroids
First line: injection into site of inflammation, if cant, then give oral formulation
Methylprednisolone 5 mg / small joint
Triamcinolone : 2.5 - 5 / small joint
Betmethasone: 1.5-3 mg
Oral Prednisone: 30-50 mg per day until flare resolve and then taper over 7-10 days
Caution with HF: increase BP, edema,
steroids SE’s
pneumonic PREDNISONE
PUD
Rash
Eye ( glaucoma )
Diabetes
Neurologic ( CNS ) : HA, mood, insomnia, seizure
Immunosuppression
Swelling ( Cushing )
Osteoporosis
Nausea ( we actually use dexamethasone to tx N/V for cisplatin. Start with 5HT then add steroid then emend )
Electrolyte ∆’s : ↑Na+, ↓K+ ( therefore increase BP )
Management of chronic gout
Urate lowering meds should not be started during acute attack. Best to start 2 weeks after the attack.
Goal : reduce urate <6
Uricosuric drugs: Probenacid , Lesinuard
Xanthine oxidase inhibitors
Allopurinol uloric
PEGylated uric acid enzyme:
Kystexxa ( Pegloticase ) IV
Probenacid
MOA: increase urinary excretion of urate.
Problem: doesn’t work well. Not first line.
Works on kidneys ( also used to increase plasma levels of PCN, cyclosporins, Nafcillins . Won’t allow you excrete these drugs so more in system. ) cydopavir can cause vancoli like renal tox so Probenacid protects the kidneys
Indication: HYPERURICEMIA with gout
Prolong PCN serum levels
With food.
Goes through kidney. Drink lots of water to keep urine alkaline. If CrCl < 50 ( clinically choose not to give ) package insert says 30
Methotrexate and Probenacid DDI
Avoid Probenacid will increase [ MTX ]
Lesinurad
Zurampic
MOA: uric acid transporter ( works on kidney ). It inhibits fxn of renal uric acid reabsorption.
Never given alone. Works in combination with allopurinol or febuxostat. If you stop these you stop add on lesinurad
With food and lots of water
Caution: avoid if CrCl < 30
Xanthine oxidase inhibitors
First line for gout prevention
MOA: blocks Xanthine oxidase
Use if uric acid production > 800
Use if patient has kidney stones
Renal failure
Allopurinol
MOA: xanithine oxidase inhibitor
Aloprim ; zyloprim
Food and lots of water
Reduce if CrCl drops. Dose adjust. CrCl 10-20 max 200 mg/ day , CrCl <10 100 mg /day
Used for Cancer therapy induced hyperuricemia: PO/IV
SE: RASH ( exfoliating dermatitis ) DC and tx with steroid
Hepatotoxicity and renal impairment
Bone marrow supression ( but minor compared to colchicine ), nausea
Monitor : CBC, uric acid levels, I & O , prothrombin time ( can enhance anticoagulant effect of warfarin )
HLAB*5801 : Han Chinese, Thai, Korean or anyone with CrCl <60
Allopurinol DDI
Azathioprine ( imuran ) turns into 6MP. Both can decrease both need xanathine oxidase to metabolize these drugs.
- decrease allopurinol by 75%
Warfarin : monitor INR, enhances warfarin
Thiazides and ACE : increases risk of hypersensitivity ( additive. Rash risk )
Bone marrow supression: reallly worry if patient is receiving alkylating agents cyclophosphamide or i phosfamide.
Vitamin C : urinary acidification : increases risk of kidney stone formation
Febuxostat
Uloric
MOA: non purine xanithine oxidase inhibitor ( but structurally different than allopurinol ). Clinically use this if you cant use allopurinol ( severe rash or HLAB5801 and cant use allopurinol , or if allopurinol not working well )
Metabolized in liver. Check LFTs uLoric
Renal metabolized too. Caution CrCL <30
Recommended to take with an NSAID or colchicine
SE: Different RASH : drug reaction rash with eosinophilia and systemic symtoms ( DRESS)
Nausea, arthralgia
Drug interactions
DDI like allopurinol
Pegloticase injection
Krystexxa
IV q 2 weeks. Given over 2 hours
MOA: a PEGylated uric acid specific enzyme. Breaks down urate
Indication: tx of chronic goat in adult patients refractory to conventional therapy
Premedicate : antihistamine, apap, IV hydrocortisone ( #1 warning is anaphylaxis )
Contraindication : G6PD deficiency
SE: GOUTY Flares ( make sure on nsaid or colchicine on first 6 months of therapy ), CHF
Thiazides, loops, levodopa, niacin( vitamin B3) , cyclosporine, tacrolimus , ethambutol, pyrazindamide, low dose asa can all increase uric acid
Alcohol ( beer with highest purine content)
High purine foods : red meat, liver kidney , shellfish and yeast can
Can call worsen or cause Gout
Paradoxical affect of ASA on serum urate
Asa not used to tx acute gout because of the paradoxical effect of salicylates on serum urate, resulting from
Renal uric acid retention at low doses ( < 2 g /day )
