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Pnt Exam 1 > Gout > Flashcards

Gout Flashcards

0
Q

tophi definition

A

aggregate deposits of sodium urate

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1
Q

hyperuricemia serum uric acid concentraitons

A

6.8 or > 7

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2
Q

renal manifestations of gout

A

urolithiasis

nephrolithiasis

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3
Q

what is gout

A

recurrent attacks of acute arthritis caused by deposits of monosodium urate crystals in tissues in and around joints

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4
Q

Risk factors for gout

A 
purine rich foods
medications
coniditions associated with hyperuricemia
age > 50 
male
increased body weight
impaired renal function
chemotherapy
elevated serum uric acid levels
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5
Q

medications that cause gout

A 
thiazide diuretics
niacin
pyrazinamide
cyclosporine
and ASA
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6
Q

conditions that are associated with high uric acid

A

HTN
dyslipidemia
Type 2 DM
coronary artery disease

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7
Q

gout attacks during chemotherapy are called

A

tumor lysis syndome

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8
Q

eliminate or uric acid

A

primarily urinary

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9
Q

what is urate

A

end product of purine degradation with no physiological purpose

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10
Q

What causes symptoms of gout

A

phagocytosis or urate crystals by luekocytes in the joint due to rapid lysis of cells and discharge of lysosomal and proteolytic enzymes into the cytoplasm

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11
Q

most commonly affected joints

A

metatarsophalageal and knee joints

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12
Q

symptoms of gout

A 
severe pain
swelling
warmth 
monoarticular
redness of joint
\+/- mild fever
tophi  (chronic severe disease) 
rapid onset usually at night
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13
Q

What tests to diagnose gout

A 
joint fluid aspiration
joint radiographs
serum uric acid levels
peripheral WBCs
ESR
24 urine excretion
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14
Q

joint fluid aspiration shows what in gout

A

monosodium urate crystals

WBCs (neutrophils predominate)

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15
Q

Joint radiographs in gout

A

cystic changes
punched out lytic lesions with overhanging bony edges
soft tissue calcified masses

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16
Q

serum uric acid levels in gout

A

can be normal or elevated during an attack

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17
Q

24 urine exretion shows > 800 mg after a purine free diet

A

overproducer

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18
Q

urine uric acid shows <600mg after a purine free diet

A

underexcretion

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19
Q

urine uric acid shows >1000mg after a regular diet

A

overproducer

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20
Q

Goals of treatment of gout

A 
achieve rapid and effective pain relief
Maintin joint function
prevent disease complications
avoid treatment AEs
Provide cost effective therapy
Improve QOL
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21
Q

Non pharm treatment for gout

A

joint rest 1-2 days with ice
weight loss
diet, health, and lifestyle recommendations

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22
Q

Nsaids FDA approved for acute gout attacks

A

Naproxen
Indomethacin
Sulindac

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23
Q

Dose of Naproxen for gout

A

1000 mg QD x 3 days, 500 mg X 7d or 750 mg now, then 250 mg Q8H

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24
Q

Indomethacin dose for gout

A

150-200 mg qd (3 divided doses) X 3 days, then 100 mg QD for 4-7 days

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25
Q

sulindac dose for gout

A

200 mg BID x 7-10 days

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26
Q

avoid NSAIDS in who

A 
peptic ulcer or risk
warfarin
renal insufficiency 
uncontrolled hypertension
heart failure
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27
Q

acute attack dose of colchicine

A

1.2 mg X 1 dose, then 0.6 mg in one hour

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28
Q

Prophylactic dose of colchicine

A

0.6 mg 1-2 times daily

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29
Q

colchicine brand name

A

colcrys

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30
Q

What is the time frame for giving colchicine for an acute attack

A

36 hours

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31
Q

what is the time frame for giving NSAIDs for an acute attack

A

within 24 hours

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32
Q

AEs of colchicine

A

diarrhea, N/V, abdominal pain

myopathy, neutropenia, alopecia (long term use), bone marrow suppression

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33
Q

Dose adjust colchicine in renal impairment

A

yes

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34
Q

reduce prophylactic dose of colchicine in who

A

age 70+

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35
Q

CIs for colchicine

A

PGP or 3A4 inhibitors in the prescence of hepatic or renal impairment

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36
Q

Avoid using colchicine with what

A

macrolides (clarithromycin)

37
Q

Colchicine should be reserved for who

A

at risk for NSAID induced gastropathy

NSAID therapy failures

38
Q

oral treatment dosage of prednisone for gout

A

0.5 mg/kg/day x 5-10 days at full dose then stop or 205 days at full dose then taper for 7-10 days

39
Q

Intrarticular treatment with corticosteroids considered when

A

know which joints involved, 1-2 joints involved

40
Q

corticosteroids used for gout in which pt population

A

CKD patients - NSAIDs not great, colchicine clearance reduce

41
Q

Intramuscular treatment of corticosteroids dose

A

Triamcinolone 60 mg, then oral prednisone

42
Q

AEs of corticosteroids

A

Increase glucose levels, fluid retention, impaired wound healing, weight gain, CNS stimulation, increased infection risk

43
Q

Cautions with corticosteroids

A

Diabetes, patients who joint sepsis cannot be excluded, psychiatric disorders, cardiovascular disease

44
Q

Why avoid long term corticosteroids

A

risk for osteoporosis, adrenal suppression, cataracts, muscle deconditioning

45
Q

Treat or not with asymptomatic hyperuricemia

A

not usually unless indication for urate lowering therapy

46
Q

indications for urate lowering therapy in asymptomatic hyperuricemia

A

tophus or tophi by clinical exam or imaging study
2+ attacks per year
CKD stage 2 or worse
uric acid nephrolithiasis

47
Q

Goal serum urate level

A

<6 mg/dL, may need lower for symptomatic improvement

48
Q

Xanthine Oxidase Inhibitors

A

Allopurinol

Febuxostat

49
Q

are xanthine oxidase inhibitors good for overproducers or underexcretors?

A

BOTH!

50
Q

xanthine oxidase inhibitor MOA

A

blocks xanthine oxidase resulting in decrease uric acid production

51
Q

Allopurinol initial dose

A

100 mg QD titrate up Q2-5 weeks until goal uric acid (max dose max 800 mg /day

52
Q

allopurinol initial dose in stage 4 or worse CKD

A

50 mg/day

53
Q

monitor serum uric acid when after starting allopurinol

A

1 week

54
Q

AEs of allopurinol

A

dose dependent skin rash
GI intolerance
headache
allopurinol hypersensitivity syndrome

55
Q

allopurinol hypersensitivity syndrome symptoms

A 
stevens johnson syndrome
toxic epidermal necrolysis
eosinophilia
vasculitis
rash
end-organ disease
56
Q

high risk populations for allopurinol hypersensitivity syndome

A

korean with stage 3 or worse CKD

han chinese or thai

57
Q

feboxostat brand name

A

uloric

58
Q

dose of febuxostat

A

40 mg qd; increase to 8 if not at goal after 2 weeks

59
Q

dose adjust febuxostat in renal impairment

A

nope

60
Q

monitoring for febuxostat

A

baseline LFT, 2+4 months, periodically

61
Q

AEs of febuxostat

A

diarrhea, rash, pharyngolaryngral pain
blood dyscrasias
arthritis
nausea

62
Q

caution with febuxostat

A

possible CV thrombotic events and increased liver enzyme

63
Q

CIs with febuxostat

A

use with azathioprine, mercaptopurine, or theophylline

64
Q

uricosuric drugs

A

probenecid
fenofibrate
losartan
sulfinpyrazone

65
Q

uricosuric drugs for who

A

underexcretors!

66
Q

uricosuric drugs MOA

A

increases renal excretion of uric acid by decreasing uric acid reabsorption in the renal tubules

67
Q

AEs of uricosuric drugs

A

GI irritation
Rash and hypersensitivity
precipitation of acute gouty arthritis
stone formation

68
Q

CIs of uricosuric drugs

A 
hypersensitive pts
impaired renal function <50 ml/min
history of renal calculi
overproducers of uric acid
history of urolithiasis
69
Q

Probenecid dosing for gout

A

250 mg BID x 1-2 weeks, then 500 mg BID x 2 weeks, max 1000 mg BID

70
Q

Drug interactions with uricosuric drugs

A

salicylates (<325 mg enteric coated ok)

71
Q

Probenecid drug interactions

A

increases concentration of penicillin, cephalosporin, sulfonamides, and indomethacin

72
Q

When to discontinue chronic treatment of gout

A

Pt w/o evidence of tophi
6-12 months after normal levels of urate are reached
consider adherence

73
Q

foods to avoid in gout

A

purine rich organ meats
high fructose corn syrup
alcohol overuse (>2 per men, >1 women)
any alcohol during gout attacks or poorly controlled gout

74
Q

foods to limit in gout

A 
beef, lamb, pork
high purine seafood
fruit juices
sugar and sweetened things
table salt (sauces and gravy)
75
Q

Foods to enourage in gout

A

low fat or non-fat dairy

vegetables

76
Q

first line for gout with no peptic ulcer risk and CrCl >30

A

NSAIDS

77
Q

second line with no peptic ulcer risk and CrCl > 30 for gout

A

Colchicine

78
Q

option for monoarticular gout with no peptic ulcer risk and CrCl > 30

A

intrarticular corticosteroid

79
Q

First line for gout attack if CrCl < 30

A

systemic corticosteroid

80
Q

first line for gout attack with peptic ulcer risk

A

colchicine

81
Q

when after acute gout treatment do you determine the need for prophylaxis

A

4-6 weeks

82
Q

First line if prophylaxis is needed with renal insufficiency +/- uric acid stones with CrCl > 30

A

febuxostat

83
Q

first line if prophylaxis needed with renal insufficiency +/- uric acid stone and CrCl < 30

A

allopurinol

84
Q

Prophylaxis is needed with no renal involvement

A

allopurinol, febuxostat if not tolerated or goal not reached

85
Q

colchicine dose in CrCl < 30

A

0.3 mg QD

86
Q

colchicine dose on dialysis

A

0.3 mg twice weekly

87
Q

colchicine dose for adults 70+

A

reduce dose by 50%

88
Q

max allopurinol dose in CrCl 10-20

A

200 mg/day

89
Q

max allopurinol dose in CrCl 3-10

A

100 mg/day

90
Q

allopurinol dose for CrCl <3

A

100 mg with extended dosing intervals

Pnt Exam 1 (6 decks)

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