Gout Flashcards
What is the goal serum uric acid level for treatment of gout?
Less than 6 mg/dL
What meds can increase risk of hyperuricemia?
Niacin
Thiazide and loop diuretics
Immunosuppressants
How is gout categorized by severity?
0-10 pain scale
- Mild is 4 or less
- Moderate is 5-6
- Severe is 7 or higher
How is gout categorized by onset?
Early - less than 12 hrs onset
Well established - 12 to 36 hrs after attack
Late - over 36 hrs since attack
How is the extent of gout categorized by joints?
- One or a few small joints
- 1 or 2 large joints (ankle, knee, wrist, elbow, hip shoulder)
- Polyarticular w/more than 1 region (4 or more joints)
Acute gout attack treatment
- NSAIDs
- Colchicine
- Corticosteroids
When should treatment be started with an acute gout attack?
Within 24 hrs if possible
NSAID use in gout
- No specific preferred (MC are indomethacin and naproxen)
- Full dose until attack is resolved (3-5 days)
- COX2 inhibitor can be used (high doses needed)
- ADEs are GI, HTN, dizzy, CV events, tinnitus
MOA colchicine in gout
Decreases microtubule assembly and inhibits activation of inflammatory response
1st line treatment of mild to moderate gout?
Monotherapy of either:
- NSAID (or COX2 inhibitor)
- Systemic steroids
- Colchicine
ADEs of colchicine
- Abdominal pain, cramping, vomiting, diarrhea
- Monitor in renal and hepatic impairment
- Narrow therapeutic range before toxicity
How should colchicine be taken?
With plenty of water
What can increase levels of colchicine?
Grapefruit juice
Drug interactions with colchicine
- Clarithromycin
- Statins
- Digoxin
How do corticosteroids work in gout?
Suppresses migration of PMN leukocytes and decreases immune repsonse
ADEs of corticosteroids
- Hyperglycemia
- Dyspepsia, nausea
- Mood changes
- HTN
How should corticosteroids be taken in gout?
- With food
- Can be given intra-articular
- Use for 5-10 days then discontinue (oral)
Nonpharm prevention of gout
- Diet (decrease purines, HFCS, sugar and salt)
- Reduce weight
- Exercise
- Reduce ETOH
- Increase fluids, rest and ice
What are the urate-lowering treatment criteria?
- Pts w/tophi
- 2 or more attacks per year
- Stage 2 to 5 CKD
- History of uric acid kidney stones
Xanthine oxidase inhibitors
Allopurinol and febuxostat
What is the 1st line treatment for gout prevention?
Xanthine oxidase inhibitors (allopurinol, febuxostat)
Should xanthine oxidase inhibitors be stopped during acute gout attacks?
NO - add colchicine or NSAID
Allopurinol ADEs
- Hypersensitivity in pts taking ACEI and diuretics
- Rash MC w/concurrent amoxicillin/ampicillin
Who is at high risk for allopurinol hypersensitivity?
HLA-B 5801 (Koreans, Han Chinese, Thai)
How should allopurinol be taken?
After meals w/fluids
What is febuxostat and how is it used?
- Potent selective xanthine oxidase inhibitor
- Used for gout (both overproduction AND underexcretion of uric acid)
ADEs of febuxostat
- Diarrhea, HA, liver function, CV risks
- Use w/caution in severe renal disease
What is an alternative 1st line treatment for gout prevention?
Probenecid (uricosuric agents) in those with contraindications or intolerance to xanthine oxidase inhibitors
What is probenecid?
- Uricosuric agent
- Alternative 1st line agent for gout prevention
- Can be combined with XO inhibitor
- Takes time to reduce plasma concentration of uric acid
Probenecid MOA
Inhibits reabsorption of uric acid at proximal tubule
Which gout med increases risk of kidney stones?
Probenecid
When should probenecid be started?
2-3 weeks after an acute attack
What are uricosuric agents?
- Used for gout prevention
- Probenecid
- Fenofibrate (unlabeled use)
- Losartan (unlabeled use)
How is fenofibrate used in gout?
- Uricosuric agent for gout prevention
- Unlabeled use
- Avoid in hepatic impairment
- Dosing changes in renal impairment
How is losartan used in gout?
- Uricosuric agent for gout prevention
- Unlabeled use
- Increases urinary flow rate and increases excretion of uric acid, Mg, Ca
What is Pegloticase and what is it used for?
- Pegylated recombinant form of uricase (enzyme normally absent in humans)
- Converts uric acid to allantoin (inactive and water soluble metabolite)
- Severe refractory chronic gout
- IV infusion
In gout, which med requires discontinuing urate-lowering and uricosuric agents?
Pegloticase
