Gout

Question 1

Patho, Sx

Answer 1

Comple form of arthritis
-Painful inflammation in joints
-Tophi, kidney stones, urate nephropahy
-High uric acid (>6/7) increases risk of acute attacks

Question 2

Risk Factors

Answer 2

-Age
-Male
-African
-Family hx
-Metabolic syndrome
-Renal insufficiency
-Diabetes
-HTN, HF
-Meat, beer, soft drinks, fructose, seafood

Question 3

Acute Management

Answer 3

Mono: mild-mod, <=6/10 pain
-NSAID (first line)
-CS (first line)
-Colchicine (first line)

Combo: severe, 7+ pain, multiple joints
-Colchicine + NSAID
-Colchicine + CS
-IA Steroid + oral agent (NSAID, CS, colchicine)

Question 4

NSAIDs + Dosing

Answer 4

1. Indomethacin 50
2. Naproxen 500
3. Ibuprofen 800
4. Celecoxib 800

Caution in elderly, renal insufficiency, heart failure, PUD, anticoagulation therapy, liver disease, asthma

Question 5

Corticosteroids

Answer 5

IA treatment of choice if only 1-2 large joints involved

Avoid use if septic joint not excluded

1. Pred 0.5 mg/kg/d
2. MP IA 20-40 x1d
3. MP IM 80-120 x1d
4. Triam IM 60 x1d

Question 6

Colchicine

Answer 6

Most effective if used within first 24 hours

AE: NVD, BMS

DDI: erythromycin, simvastatin, cyclosporine

Dose: 1.2 mg PO then 0.6 mg 1 hr later

Question 7

Colchicine for Prophylaxis

Answer 7

CrCl > 50: 0.6 QD-BID

CrCl 35-49: 0.6 QD

CrCl 10-34: 0.6 Q2-3d

< 10: avoid

Question 8

Chronic Management

Answer 8

XOIs
-Allopurinol
-Febuxostat

Start during acute attack, target urate < 6

Top 1+, radiograph damage, freq >2/yr

Question 9

Allopurinol

Answer 9

100 mg QD
-Increase by 100 mg Q2-5 weeks

HLA-B*5801 screening in high-risk patients

DDI: azathioprine, mercaptopurine, warfarin

AE: GI, LFTs, rash

Question 10

Febuxostat

Answer 10

40 mg QD
-Increase to 80 mg after 2-5wk

Consider not using in ASCVD hx

CI:
-Azathioprine
-Mercaptopurine
-Theophylline

AE:
-Increase CV/TE events
-LFTs
-Nausea, rash

Question 11

Second-line for Chronic Management

Answer 11

-Intolerant of XOIs
-Combo for refractory hyperuricemia

Agents:
-Probenacid
-Pegloticase
-Lesinurad

Question 12

Probenecid

Answer 12

CI in urolithiasis

Avoid in 700+ uric acid

DDI: heparin, salicylates, abx

*has u prob 700

Question 13

Pegloticase

Answer 13

AE:
-Anaphylaxis
-Infusion rxns
-Gout flares
-HF

CI:
-G6PD def

REMS

Question 14

Lesinurad

Answer 14

Approved for gout only in combination with XOIs

Avoid CrCl <45

BBW for renal failure if used w/o XOI

*less than 45, renal failure combo

Question 15

Non-Pharm Tx

Answer 15

-Rest
-Ice
-Avoid triggers? (infection, trauma, surgery, diuretics)
-Diet (avoid meats, fructose, alcohol)
-Weight reduction