Gout

Question 1

Hyperuricemia

what meds involved?

Question 2

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

Answer 2

• Podagra

Question 3

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

Answer 3

• Tophi
• kidney stones

Question 4

Diagnosis

___ fluid aspiration

In clinical practice
- Monoarticular involvement
- Previous episodes
- Rapid onset of pain,
swelling, and erythema
- Risk factors

Answer 4

synovial

Question 5

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

Answer 5

early

Question 6

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)

Answer 6

• Methylprednisolone

Question 7

Corticosteroid Considerations

• ___ PO courses
• Limit treatment duration
• increased risk of GI bleed and peptic ulcer disease
• Close monitoring of ___
• Avoid IA injection if suspect ___

Answer 7

• taper
• diabetes
• infection

Question 8

Colchicine

MOA: disrupts cytoskeletal functions by inhibiting β-tubulin polymerization into
microtubules, thus preventing the activation, degranulation, and migration of ___ associated with gout symptoms

Answer 8

neutrophils

Question 9

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

Answer 9

• 24
• 1.2
• BID

Question 10

Colchicine AE

• N/V/D
• ___
• axonal ___

Answer 10

• neutropenia
• neuromyopathy

Question 11

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

Answer 11

• 2
• 0.6
• 2

Question 12

Hepatic Dose Adjustment - Colchicine

severe - no dose adjustment: course should be repeated no more than once every ___ weeks

Answer 12

2

Question 13

Colchcine DI

strong ___ and ___ inhibitors

Answer 13

CYP3A4
P-gp

Question 14

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

Answer 14

• NSAIDs, steroids

Question 15

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

Answer 15

• Asymptomatic

Question 16

Urate Lowering Therapy (ULT)

Duration of therapy: ___

monitoring
- serum ___
- treat to target of < __ mg/dL

Answer 16

• indefinitely
• uric acid
• 6

Question 17

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 ___

Answer 17

• allopurinol
• febuxostat

Question 18

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

Answer 18

• 50
• hypersensitivity
• HLA-B*5801

Question 19

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

Answer 19

• uric

Question 20

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)

Answer 20

• CV
• 20

Question 21

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

Answer 21

reabsorption
Probenecid

Question 22

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

Answer 22

• urolithiasis
• G6PD

Question 23

Uricase Agents (3rd line)

MOA: recombinant form of urate-oxidase enzyme (uricase) that converts uric acid to the more soluble ___

Answer 23

• allantoin

Question 24

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

Answer 24

• tophi
• anaphylaxis
• G6PD
• immunogenicity

Question 25

other ULT meds

___ and ___

Answer 25

fenofibrate
losartan

Question 26

Gout Attack Prophylaxis

• ___
• ___ ( < ___ mg/day)
• ___

duration
- during initiaition of ULT (3-6 months or longer if indicated)

Answer 26

• NSAIDs
• prednisone
• colchicine

Question 27

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)

Answer 27

• 0.6
• 0.3
• weekly