Gout Flashcards
what is gout
inflammatory process in response to crystallization in articular and non-articular tissue
what is hyperuricemia classified as
uric acid > 6.8 mg/dL AND symptomatic
what is main product in purine degradation
uric acid
what is a byproduct of uric acid breakdown
allantoin
how is uric acid overproduced
increase in dietary purines
chronic alcohol intake
cytotoxic meds
regulatory enzyme variability
how is uric acid underexcreted
dehydration
medications
acute alcohol intake
insulin resistance
medications that cause hyperuricemia
diuretics
salicylates (<2 g/day)
cytotoxic drugs
risk factors for gout
male
post menopausal women
elderly
obesity
diet
alcohol intake
sedentary lifestyle
renal impairment
presentation of acute gout
acute inflammatory monoarthritis
podagra
uric acid deposit in fingers, cartilage, kidneys
symptoms of acute gout
fever
intense pain
erythema, warmth, edema, inflammation of joints
lab tests to confirm acute gout
uric acid > 6.8 mg/dL
WBC > 11,000
what is podagra
big toe joint inflamed and big
what is tophi
deposits of monosodium erate
bumps in fingers and feed
what is gouty nephropathy
acute and chronic kidney disease
how do we get a true diagnosis of gout
synovial fluid aspiration to see pins and needles
non-pharm therapy for acute gouty arthritis
ice
risk factor modification
drug class options for acute gouty arthritis
NSAIDs
corticosteroids
colchicine
NSAID options for acute gouty arthritis
indomethacin
naproxen
ibuprofen
sulindac
adverse effects NSAIDs
GI effects
kidney injury
CV effects
CNS effects (headache,dizzy)
bleeding risk
if pt has an ASA allergy should we do NSAID
no, choose something else
when do we initiate treatment for acute gouty arthritis
ASAP
corticosteroid options for acute
PO medrol dose pack
PO prednisone tapered
IM triamcinolone or methylpred
intra-articular triamcinolone
corticosteroid adverse effects
hyperglycemia
increased BP
GI upset
anxiety/restlessness
insomnia
fluid retention
what corticosteroids should be tapered?
PO
what drugs have increased risk GI bleed and ulcer
corticosteroids
if pt has infection what dosage form to avoid
intra-articular
when is colchicine given
within 24 hours of acute attack
brand of colchicine
Colcrys
dosing of colchicine
day 1: 1.2 mg once then 0.6 mg 1 hr later
day 2+: 0.6 mg BID until resolved
colchicine adverse effects
N/V/D
neutropenia
axonal neuromyopathy
colchicine renal adjustments
CrCl >30 no adjust
CrCl < 30 1.2 at onset then 0.6 1 hr later, not repeated more than once every 2 weeks
dialysis: one 0.6 mg dose, not repeated more than once every 2 weeks
hepatic dosage adjustment colchicine
mild to moderate: none
mod to severe: none, dont take more than once in two weeks
what if pt has inadequate response to initial adequate treatment
<50% improvement in pain in 24h
switch agents
add 2nd agent but avoid NSAIDs w PO corticosteroids
what is pill in pocket
used if pt gets sx of acute flare
NSAID or colchicine
non pharm therapy for chronic gout
weight loss
avoid sat fats and sweetened beverages/foods
alcohol restriction
limit purine rich foods
who is a candidate for ULT chronic
2+ flares per year
1+ tophus
radiographic evidence of gout
1+ prior flare
first flare + CKD, uric >9, urolithiasis
who is not a candidate for ULT
asymptomatic hyperuricemia with no prior flares or tophi
first attack with no risk factors
monitoring for ULT
serum uric acid
target < 6
treatment classes for chronic gout
1st line xanthine oxidase inhibs
2nd line uricosurics
3rd line uricase agents
xanthine oxidase inhibitor drugs
allopurinol
febuxostat
xanthine oxidase inhibitors MOA
reduce uric acid by impairing ability of xanthine oxidase to convert hypoxanthine to xanthine (which is then converted to uric acid)
allopurinol dose
100 mg PO daily
CrCl < 30: 50 daily, titrate slowly
max 800 mg
titrate by < 100 mg every 2-4 weeks to achieve uric acid < 6
febuxostat dose
40 mg PO daily
CrCl < 30: 20 mg daily
titrate to 80 mg if uric acid > 6 after 2 weeks
allopurinol drug interactions
loop and thiazide
warfarin
azathioprine, 6MP, flurouracil
adverse reactions allopurinol
rash
headache
uticaria
hypersensitivty: steven johnson
what is the biggest risk factor for allopurinol hypersensitivity steven johnson syndrome
HLA-B*5801 allele +
south asian descent
monitoring for allopurinol
uric acid q2-5 weeks while titrating
every 6 month when stable
febuxostat black box warning
increased CV mortality
urosicase drugs MOA
increase clearance of uric acid by inhibiting reabsorption in proximal tubule
urosicase drug
probenecid
probenecid dosing
250 BID x1-2 weeks
titrate in 500 mg incremements every 1-2 weeks till benefit
probenecid adverse reactions
urolithiasis - contraindicated
probenecid renal considerations
not reccommended if eGFR < 60
pegloticase MOA
converts uric acid to allantoin
when is pegloticase used
SEVERE gout
failed xanthine and urosicase
> 3 gout flares in 18 month
1+ tophi
joint damage
pegloticase dosage form
IV infusion over 2 hours every 2 weeks
what do we do with pegloticase
pre-medicate
black box warning pegloticase
infusion related reactions
G6P deficiency may cause hemolysis
other option for uric acid lowering
fenofibrate - increase clearance
losartan - inhibit reabsorption
preferred agent in pts with HTN and gout when able
losartan
when initiating ULT how should we prophylax and how long?
first 3-6 months of ULT
NSAIDs - low dose
steroids - pred < 10 mg/day
colchicine
colchicine prophylaxis dosing
0.6 mg daily or BID
CrCl < 30: consider alt, or 0.3 mg daily
dialysis: 0.3 mg twice weekly
what should we not give if mental health disorder
steroids
what should we not give if HTN
steroids
NSAIDs
