Gout

Question 1

Acute gout

Answer 1

Severe pain and erythema, typically in one joint, follow-up attacks may involve more joints

Question 2

Chronic tophaceous gout

Answer 2

persistent pain and joint stiffness involving many joints; soft tissue mass of urate crystals in areas of low body temperature; attacks are frequent and there are persistently elevated serum uric acid concerntrations

Question 3

How is uric acid made in the body

Answer 3

purines break down into xanthine then into uric acid

Question 4

What is the mechanism of gout?

Answer 4

1. water diffuses out of the joint
2. uric acid concentration is increased which leads to crystal formation
3. inflammatory cascade

Question 5

What are lifestyle risk factors of gout

Answer 5

obesity, seafood, red meat, alcohol

Question 6

What are medical conditions that are risk factors of gout

Answer 6

DM and renal disease

Question 7

What are medication risk factors for gout

Answer 7

thiazide diuretics, low/mod dose aspirin, ACE/ARB

Question 8

What are the 4 stages of gout

Answer 8

1. Asymptomatic
2. Acute gouty arthritis
3. Intercritical gout
4. Chronic recurring gout

Question 9

What is the treatment for a gout flare

Answer 9

1. first line: colchicine, NSAIDs, or corticosteroids
2. continue prophylaxis treatment for 3-6 months

Question 10

How to treat a frequent flare of gout or 1 or more Tophi

Answer 10

1. start urate lowering therapy
2. first line - Allopurinol
3. serum urate goal <6mg/dL
4. Start urate lowering therapy during flare instead of after resolution

Question 11

What are nonpharmacological recommendations for gout

Answer 11

1. limit intake of alcohol, purines, and high fructose corn syrup
2. Weight loss

Question 12

What is the approach to managing gout?

Answer 12

Do not start long-term therapy following first gout flare or in those with infrequent flares (<= 2 flares per year

Question 13

Acute flare treatment/prophylaxis?

Answer 13

NSAIDs, Colchicine, Corticosteroids

Question 14

Chronic management?

Answer 14

Allopurinol, Febuxostat, Probenecid

Question 15

What can be done if flare is severe or several joints are effected?

Answer 15

Combination therapy with colchicine, NSAIDs, and oral corticosteroids

Question 16

What is colchicine MOA?

Answer 16

1. Anti-inflammatory
2. Prevents migration of neutrophils to sites of inflammation
3. Not an analgesic - won’t directly stop pain

Question 17

What is colchicine efficacy?

Answer 17

50% reduction in pain at 24 hours

Question 18

What is the dosing for colchicine?

Answer 18

1. tablet is 0.6 mg
2. 1.2 mg within 12 hours of onset and 0.6 mg 60 minutes later (do not repeat for 3 days)
3. Gout prophylaxis - 0.6 mg 1-2 times daily (max 1.2mg/day and wait 12 hours after acute gout flare before resuming prophylaxis)

Question 19

Adverse effects of colchicine?

Answer 19

GI discomfort and diarrhea

Question 20

Safety of colchicine?

Answer 20

> 4mg multiple organ failure and death

Question 21

How does colchicine relate to NSAIDs in terms of pain relief?

Answer 21

More delayed onset of effect than NSAIDs for pain relief

Question 22

When should corticosteroids be used for gout?

Answer 22

last-line agent

Question 23

Adverse effects of corticosteroids?

Answer 23

diabetes/hyperglycemia

Question 24

Nonpharmacologic prevention of recurrent gout attacks?

Answer 24

1. Adequate hydration
2. Diuretic therapy discontinuation
3. low-moderate impact exercise
4. restrict purine and alcohol intake
5. weight reduction

Question 25

What are the expectations of preventing gout attacks?

Answer 25

therapy goal - serum uric acid concentration <5-6 mg/dL
Evaluate serum uric acid concentrations every 3 months for the first year then annually there after

Question 26

What are the Xanthine Oxidase Inhibitors?

Answer 26

1st line - Allopurinol (Zyloprim)
alternative - febuxostat (Uloric)

Question 27

How do Xanthin Oxidase inhibitors work?

Answer 27

decrease uric acid production, do not lower current uric acid levels, may lead to gout flare

Question 28

What is allopurinol MOA?

Answer 28

Urate lowering therapy
Inhibits production of uric acid by inhibiting xanthene oxidase enzyme

Question 29

Allopurinol efficacy?

Answer 29

1. prevent recurrent gouty arthritis attacks
2. Reduce uric acid concentrations

Question 30

How often is allopurinol taken?

Answer 30

Daily

Question 31

Adverse effects of allopurinol?

Answer 31

Well tolerated
Transient rash

Question 32

Safety concerns of allopurinol?

Answer 32

SJS
decreased excretion of allopurinol when taken with thiazide

Question 33

What should be done if patient has a rash with allopurinol?

Answer 33

Stop using and don’t try again

Question 34

When should allopurinol not be used?

Answer 34

asymptomatic hyperuricemia

Question 35

Should allopurinol be stopped during an acute attack?

Answer 35

No

Question 36

What is the efficacy of febuxostat?

Answer 36

greater efficacy for reducing uric acid concentration, but no more efficacious for preventing gout flares

Question 37

What are the adverse effects of febuxostat?

Answer 37

Arthralgias and nausea

Question 38

What is the safety of febuxostat?

Answer 38

1. CI in patients using azathioprine, mercaptopurine, or theophylline
2. Higher incidence of cardiovascular events observed compared with allopurinol

Question 39

What is a specific use of febuxostat?

Answer 39

reduce tophi

Question 40

Should febuxostat be used in patients with asymptomatic hyperuricemia?

Answer 40

No

Question 41

What is probenecid MOA?

Answer 41

inhibition of a renal tubular transporter

Question 42

What is the safety of probenecid?

Answer 42

1. Avoid in patients with uric acid kidney stones
2. Many drug interactions

Question 43

What is important to remember when prescribing probenecid?

Answer 43

ineffective in patients with even mild renal insufficiency