gout Flashcards
where does Gout typically occur and what causes it?
Typically occurs in the metatarsophalangeal joint (MTP, big toe) and is due to many years of persistent hyperuricemia.
Risk Factors for gout
-Male sex, Overweight, Excessive alcohol intake (beer), Hypertension, Renal insufficiency, Advanced age, Medication (Diuretics, niacin, aspirin, and pyrazinamide
Treatment Goals for gout
Treat acute attacks, Prevent future flare-ups, Reduce UA levels
What are the first line agents for Acute Gout Attack Treatments
-Colchicine (Colcrys); NSAIDS: Indomethacin (Indocin), Naproxen (Naprosyn), Sulindac (Clinoril),Celecoxib (Celebrex); Steroids:Prednisone, Methylprednisolone, Triamcinolone
Colchicine (Colcrys) moa
Inhibits beta-tubulin polymerization
Administration directions for Colcrys initiation
-At first sign of attack take 2 tablets (1.2mg) followed by 1 more tablet (0.6mg) in one hour (max = 1.8 mg/day);
NSAIDs used in Gout & when should they be avoided?
-Indomethacin (Indocin), Naproxen (Naprosyn), Sulindac (Clinoril), Celecoxib (Celebrex); Avoid use in severe renal disease
What are the side effects of indomethacin
psychiatric: confusion, depression, psychosis
What dose of Naproxen is used in gout & for how long
750mg once, then 250mg q8h until attack resolves
What is the dose of Indocin for gout
50mg, TID till attack resolves
For gout, what are the routs of administration of steroids?
PO, IM, IV, intra-articular or ACTH( adrenocorticotropic hormones)
what are the acute side effects of steroids
Side effects: increased blood glucose, elevated blood pressure, nervousness, insomnia, increased appetite, and edema
which steroids are used intra-articularly for gout
Methylprednisolone and triamcinolone is given intra-articularly based on joint size
Which medications can be used for Prophylactic Treatment (lowering of uric acid production)
Allopurinol (Zyloprim), Febuxostat (Uloric), Probenecid, Pegloticase (Krystexxa)
Prior to initiation of UA-lowring therapy what should the patient do?
take colchicum 0.6mge daily or BID or NSAIDs for at least 6 months to reduce acute flares
What are Xanthine oxidase inhibitors and how doe they work
Allopurinol(Zyloprim) & Febuxostat(Uloric); MOA: block UA prodution
Side effects of Allopurinol (Zyloprim) & renal adjustment
Side effects: precipitation of gout attacks, increase LFTs, and skin rash; Dose adjust if CrCl <20
What are the warning for Zyloprim (allopurinol
Hypersensitivity: test HLAB*5801 prior to start, hepatotoxicity
What is the initial dose of allopurinol
50-100mg/day; slowly titrate to UA target; doses >300mg needed in pts w/ CKD
Couseling for Allopurinol
take once daily with a meal to Reduce stomach upset, May take up to several weeks for medicine to be effective, If you get a rash, notify your doctor
Febuxostat (Uloric) is ideal for whom and why?
For resistant cases b/c it is very expensive, and possibly in renal disease as no dose adjustment needs to be made
What are the contraindications to Uloric use
concurrent use with azathiopurine or mercaptopurine
What are the side effects & warnings of Uloric
-Side effects: liver enzyme elevation, rash; Warning: Hepatotoxicity(eps in liver impairment) increased thrombocytopenic events
Probenecid MOA & indication
-Uricosuric: Inhibits the reabsorption of uric acid; indicated when XO inhibitors are CI, not tolerated or added if UA level not at goal w/ max dose of XO-inhibitor
What interactions does probenecid have
may decrease renal clearance of (aspirin, methotrexate, theophylline, penicillins)
What are the contraindications to probenecid?
Concomitant use of aspirin; uric acid kidney stones; blood dyscrasias, starting during an acute attack, CrCl <30ml/min
What are the side effects & warnings of Probenecid?
Side effect: hypersensitivity rtxn, hemolytic anemia; Warning: increased risk hemolytic anemia in G6PD deficient pts
pts on uricosurics must have what?
good renal function. if pt’s CrCl <50, this can not be used mono therapy
Pegloticase (Krystexxa) class and MOA
recombinant Uricase enzyme: converts uric acid to an inactive water-soluble metabolite that can be easily excreted.
In what cases is pegloticase (Krystexxa) indicated for use?
Used in resistant cases only
What are the side effects of pegloticase (Krystexxa)
Antibody formation, gout flare, infusion rxtn, urticaria, erythema, pruritus, bruising
Pegloticase (Krystexxa) is never to be used in combination with which gout agent?
allopurinol
Pegloticase BBW, how is it managed & who is at risk
Anaphylactic rxtn: during infusion; premeditate with antihistamines & steroids; highest risk if UA level >6mg/dl (D/C) therapy
Krystexxa (pegloticase) is contraindicated in which condition
G6PD deficiency
do not use X for acute treatment
ASPIRIN (bufferin included in this)
food to avoid
organ meats, high fructose corn syrup & alcohol, fruit juice, table sugar, sweetened drinks, salt, beef, seafood )high in purine sward fish, shellfish)
what is the normal serum uric acid level
-Normal serum uric acid levels: 2.0 - 7.2
How is uric acid produced
Uric acid is produced as an end-product of purine metabolism
What are the side effects & warnings of Colchicine (Colcrys)
Side effects: nausea, vomiting, abdominal pain, diarrhea; Warning: decreased clearance in renal & hepatic impairment
What interactions does Colcrys have & how are they managed?
interacts with 3A4 inhibitors (clarithromycin) and P-gp inhibitors (cyclosporine); a max dose of 1.2mg (2 tablets) can be used acutely if using these agents
how many days should a patient wait before starting another course of therapy
Wait at least 3 days before initiating another course of therapy
When is the second dose of colchicine not given
-You should not take the 2nd dose if you have upset stomach, nausea, and diarrhea
What is the prophylactic dose of colchicine
0.6mg BID starting 12 hours after acute dosing & continued till attack resolves
Colchicine is contraindicate if
pt is taking P-gp or strong CYP 3A4 inhibitor & they have renal or liver impairment
When is the ideal colcrys initiation time?
within 36 hours of onset & only if pt has not used it prophylacticly & used acute regimen in the last 14 days
Medications known to increase Uric acid
Diuretics( thiazides & loops), niacin, aspirin (higher doses), pyrazinamide, cyclosproin, tacrolimus
What is the target Uric acid level for chronic therapy with XO-inhibitors
<5-6mg/dl
