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PHRM 864 Exam 4 > Gout > Flashcards

Gout Flashcards

1
Q

Gout

A

Inflammatory process in response to crystallization of monosodium urate in articular and non-articular tissues

Hyperuricemia: uric acid > 6.8 mg/dL

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2
Q

Epidemiology

A

Men are more likely to be affected by gout

Genetics
Dietary intake
Socioeconomic factors

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3
Q

Overproduction

A

regulatory enzyme variability

cytotoxic medications

increase dietary intake of purines

chronic alcohol intake

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4
Q

Underexcretion

A

Dehydration

Insulin resistance

Acute alcohol intake

Medications

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5
Q

Medications that can cause hyperuricemia

A

Diuretics

Cytotoxic drugs

Salicylates

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6
Q

Risk factors

A

Male
Post-menopausal women
Elderly
Obesity
Diet and alcohol intake
Sedentary lifestyle
Renal impairment

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7
Q

Presentation

A

Acute, inflammatory mono arthritis

Podagra: first metatarsal joint often involved

Uric acid can deposit elsewhere: fingers, wrist, cartilage, kidnets

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8
Q

Signs and symptoms

A

Fever

Intense pain

Erythema, warmth, edema, inflammation of the affected joints

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9
Q

Laboratory tests

A

Uric acid > 6.8 mg/dL
WBC > 11,000 cells/uL

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10
Q

Complications

A

Tophi: deposits of monosodium urate

Nephrolithiasis: kidney stones

Gouty nephropathy

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11
Q

General treatment approach

A

Treatment of pain and inflammation

Use of urate lowering therapy

Anti-inflammatory prophylaxis

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12
Q

Non-pharmacologic Therapy for acute attacks

A

Modify risk factors if able

Applying ice to the affected area

No supplement that shows benefit

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13
Q

Acute gouty attacks treatment

A

NSAID
Corticosteroids
Colchicine

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14
Q

NSAID adverse effects

A

GI bleeding

Kidney injury

CV effects

CNS effects

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15
Q

Corticosteroid formulations

A

Oral: medrol 4 mg dose pack, prednisone 0.5 mg/kg/day, tapered

IM: triamcinolone 60 mg x 1, methylprednisolone 100 mg x 1

Intra-articular: triamcinolone 10-40 mg (large joints), 5-20 (small joints)

If using IM/IA, follow with NSAID or PO corticosteroid

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16
Q

Corticosteroid considerations

A

Taper

Limit duration

Increase risk of GI bleed

Monitor DM

Avoid IA if infection is present

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17
Q

Colchicine

A

Administer within 24 hours of acute attack

Capsule, tablet, solution

DOSE:
Day 1: 1.2 mg PO once, then 0.6 mg one hour later
Day 2+: 0.6 mg BID until attack resolves

18
Q

Colchicine side effects

A

N/V/D

19
Q

Colchicine renal dose adjustments

A

CrCl < 30 mL/min

1.2 mg at onset, 0.6 mg 1 hour late (once)

Treatment course should be repeated no more than once every 2 weeks

20
Q

Inadequate initial response

A

< 50% improvement in pain in 24 hours

Switch agents

Add a 2nd recommended agent: try to avoid NSAIDS with PO corticosteroids

21
Q

Non-pharm for chronic management

A

Weight loss

DASH diet

Avoid foods high in saturated fats and sweetened beverages/food

Alcohol restriction

Limiting restriction of purine-rich foods

22
Q

Indications for starting ULT

A

Frequent gout flare > or equal to 2 per year

> or equal to 1 tophus

Radiographic evidence

> 1 prior flare, but infrequent ( < 2 per year)

Patient experiencing first flare in the presence of 1 of the following: CKD stage 3-5, uric acid > 9 mg/dL

23
Q

Who is not a candidate for ULT?

A

Asymptomatic hyperuricemia with no prior gout flares or tophi

First gout attack without risk factors

24
Q

Xanthine oxidase inhibitors MOA

A

Reduces uric acid by impairing the ability of xanthine oxidase to convert hypoxanthine to xanthine and therefore uric acid

25
Q

Allopurinol

A

Initial dose: 100 mg PO daily

Titrate every 2-4 weeks in < 100 mg increments as needed to achieve uric acid < 6

26
Q

Febuxostat

A

Initial dose: 40 mg daily

Titrate to 80 mg daily if uric acid > 6 after 2 weeks

27
Q

Allopurinol renal dose adjustments

A

CrCl < 60: initial dose
50 mg daily

Titrate slowly and in small increments, may consider doses > 300 mg with close monitoring

28
Q

Allopurinol adverse reactions

A

rash
HA
hives
hepatotoxicity
hypersensitivity

29
Q

Allopurinol hypersensitivity syndrome

A

Steven-Jonhson syndrome and toxic epidermal necrolysis

Risk factors:
Female
> 60 yo
High initial doses
CKD
CV disease

HLA-B* 5801 allele: Southeast Asian decent

30
Q

Allopurinol monitoring

A

Uric acid every 2-5 weeks while titrating, every 6 months when stable

Renal function, LFTs

31
Q

Allopurinol counseling

A

Drink plenty of fluids

Take this medication even when you do not have gout symptoms

32
Q

Uricosuric Drugs MOA

A

Increase renal clearance of uric acid by inhibiting post-secretory renal proximal tubular reabsorption of uric acid

33
Q

Probenecid

A

Initial dose: 250 mg PO BID x 1-2 weeks–>increase to 500 mg BID

Titrate by 500 mg increments every 1-2 weeks

34
Q

Probenecid ADRs

A

Urolithiasis–>CI in patients with history

G6PD deficiency
Not recommended in eGFR < 60

35
Q

Uricase Agents MOA

A

Recombinant form of urate-oxidase enzyme that converts uric acid to the more soluble metabolite, allantoin

36
Q

Pegloticase

A

Used in SEVERE gout and hyperuricemia

> 3 gout flare within 18 months
1 tophi
Joint damage due to gout

IV infusion: 8 mg every 2 weeks

37
Q

Pegloticase ADRs

A

BBW: anaphylaxis and infusion reactions, G6PD deficiency-associated hemolysis and methemoglobinemia

38
Q

Pegloticase when to use

A

Patients who have failed xanthine oxidase inhibitors, uricosurics who continue to have gout flares

Patients with non-resolving tophi

39
Q

Gout attack prophylaxis

A

Use when initiating ULT

Goal is to decrease attacks

First 3-6 months

40
Q

Agents for prophylaxis

A

NSAIDS at the lowest effective dose

Prednisone < 10 mg/day

Colchicine: CrCl < 30–> 0.3 mg daily

PHRM 864 Exam 4 (22 decks)

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