Gout Flashcards
Hyperuricemia
what meds involved?
Acute Gouty Arthritis
Presentation
- Acute, inflammatory monoarthritis
- ___ – first metatarsal joint often involved
- Uric acid can deposit elsewhere
- Fingers or wrist
- Cartilage or tendons
- Kidneys
Signs and symptoms
- Fever
- Intense pain
- Erythema, warmth, edema, & inflammation of the affected joints
- Podagra
Acute Gouty Arthritis
Laboratory Tests
- Elevated uric acid
- Uric acid > 6.8 mg/dL
- WBC > 11,000 cells/μL
Complications
- ___ – deposits of monosodium urate (MSU)
- Nephrolithiasis – ___ ___
- Gouty nephropathy – acute and chronic kidney disease
- Tophi
- kidney stones
Diagnosis
___ fluid aspiration
In clinical practice
- Monoarticular involvement
- Previous episodes
- Rapid onset of pain,
swelling, and erythema
- Risk factors
synovial
NSAIDs
___ initiation is key
Indomethacin (Indocin®)
- 50 mg PO TID until flare resolves
Naproxen (Aleve®)
- 750 mg PO followed by 250 mg q8h
until flare resolves
Ibuprofen (Advil®)
- 400 mg PO TID until flare resolves
Sulindac (Clinoril®)
- 200 mg PO BID until flare resolves
early
Corticosteroid Formulations
Oral (PO)
- ___ 4 mg dose pack
- Prednisone 0.5 mg/kg/day, tapered
Intramuscular (IM)
- Triamcinolone 60 mg IM x1
- Methylprednisolone 100 mg IM x1 *may repeat x1
Intra-articular (IA)
* Triamcinolone
* 10-40 mg (large joints)
* 5-20 mg (small joints)
* If using IM/IA options, follow with subsequent anti-inflammatory agent (NSAID, PO corticosteroid)
- Methylprednisolone
Corticosteroid Considerations
- ___ PO courses
- Limit treatment duration
- increased risk of GI bleed and peptic ulcer disease
- Close monitoring of ___
- Avoid IA injection if suspect ___
- taper
- diabetes
- infection
Colchicine
MOA: disrupts cytoskeletal functions by inhibiting β-tubulin polymerization into
microtubules, thus preventing the activation, degranulation, and migration of ___ associated with gout symptoms
neutrophils
Colchicine
Recommended to administer within ___ hours of
acute attack
Dosing:
- Day 1: ___ mg PO once, then 0.6 mg one hour later
- Day 2+: 0.6 mg ___ until attack resolves
- 24
- 1.2
- BID
Colchicine AE
- N/V/D
- ___
- axonal ___
- neutropenia
- neuromyopathy
Renal Dose Adjustments - colchicine
CrCl < 30
- 1.2 mg at onset, 0.6 mg 1 hour later (once)
- Treatment course should be repeated no more than once every ___ weeks
dialysis
- single ___ mg dose; treatment course should be repeated no more than once every __ weeks
- 2
- 0.6
- 2
Hepatic Dose Adjustment - Colchicine
severe - no dose adjustment: course should be repeated no more than once every ___ weeks
2
Colchcine DI
strong ___ and ___ inhibitors
CYP3A4
P-gp
Inadequate Initial Response
- < 50% improvement in pain in 24 hours: Switch agents
- Add a 2nd recommended agent
- Try to avoid ___ with PO ___
- pill in pocket method with colchicine or NSAIDs
- NSAIDs, steroids
Chronic Gout Management
Urate Lowering Therapy (ULT)
Indications to start ULT:
* Frequent gout flares ≥ 2 per year
* ≥ 1 tophus
* Radiographic evidence of damage attributable to gout
* > 1 prior flare, but infrequent (< 2 per year)
* Patients experiencing first flare in the presence of 1 of the following:
* CKD stage 3-5
* Uric acid > 9 mg/dL
* Urolithiasis
Who is not a candidate?
- ___ hyperuricemia with no prior gout flares or tophi
- First gout attack without risk factors
- Asymptomatic
Urate Lowering Therapy (ULT)
Duration of therapy: ___
monitoring
- serum ___
- treat to target of < __ mg/dL
- indefinitely
- uric acid
- 6
Pharmacologic Therapy
Xanthine Oxidase Inhibitors (1st line)
MOA: reduces uric acid by impairing the
ability of xanthine oxidase to convert
hypoxanthine to xanthine and therefore to uric acid
2 drugs: ___ and ___
- allopurinol
- febuxostat
Allopurinol
Renal impairment
- eGFR ≤ 60: initial dose - ___ mg daily
* Titrate slowly and in small increments, may consider doses
> 300 mg with close monitoring
DI
- diuretics, warfarin, AZA, flurouracil, 6-MP
ADR
- rash
- HA
- urticaria
- hepatotoxiity
- ___ rxn
SJS or TEN with ___ allele (asian)
- female
- age > 60
- high initial doses > 100 mg/day
- CKD
- CV disease
- 50
- hypersensitivity
- HLA-B*5801
Allopurinol
monitoring:
- ___ acid every 2-5 weeks while titrating, every 6 months
- renal function, LFTs
counseling
- drink plenty of ___
- Take this medication even when
you do not have gout symptoms
- uric
Xanthine Oxidase Inhibitors (1st
line)
Febuxostat
- BBW - increased ___ mortality
- Reserved for patients unable to tolerate allopurinol
- ADR: N, arthralgias, rash
- CrCl < 30: ___ mg daily (max 40 mg)
- CV
- 20
Uricosuric Drugs
MOA: increase renal clearance of uric acid by inhibiting post-secretory renal proximal tubular ___ of uric acid
___ (Probalan®)
- Initial dose: 250 mg PO BID x 1-2 weeks -> increase to 500 mg BID
- Titrate by 500 mg increments every 1-2 weeks
- Maximum dose: 2 g/day
reabsorption
Probenecid
Probenecid
ADR
- GI irritation
- rash
- ___ - CI in patients with Hx
Caution
- ___ deficiency
- not recommended eGR < 60
DI
- inhibits tubular secretion of organic acids – mayincrease concentration
- Penicillins, cephalosporins, sulfonamides, and indomethacin
- urolithiasis
- G6PD
Uricase Agents (3rd line)
MOA: recombinant form of urate-oxidase enzyme (uricase) that converts uric acid to the more soluble ___
- allantoin
Uricase Agents (3rd line)
Pegloticase (Krystexxa)
- used in SEVERE gout and hyperuricemia
- dose: 8 mg q 2 weeks
Place in therapy:
- Patients who have failed xanthine oxidase inhibitors, uricosurics who continue to have gout flares
- Patients with non-resolving subcutaneous ___
BBW
- ___
- ___ deficiency
ADR
- GI - constipation, nausea, vomiting
- Chest pain
- Nasopharyngitis
Pearls
- ___ – patient may develop antibodies that result in lack of
efficacy
- Screen patients at risk for G6PD deficiency: African, Mediterranean , and
Southern Asian ancestry
- tophi
- anaphylaxis
- G6PD
- immunogenicity
other ULT meds
___ and ___
fenofibrate
losartan
Gout Attack Prophylaxis
- ___
- ___ ( < ___ mg/day)
- ___
duration
- during initiaition of ULT (3-6 months or longer if indicated)
- NSAIDs
- prednisone
- colchicine
Prophylaxis: Colchicine
normal: ___ mg once or twice daily
CrCl < 30 consider alternate therapy. If not able, then reduce to:
- CrCl < 30mL/min ___ mg daily (starting dose)
- Dialysis 0.3 mg twice ___ (starting dose)
- 0.6
- 0.3
- weekly
