Gout

Question 1

Pathophysiology of Gout

Answer 1

Abnormal deposit of urate in joints (can also impact kidneys as well)

Question 2

What are key diagnostic features of gout?

Answer 2

• Male
• Use of gout-inducing medications
• Consumption of high-purine food
• Hx of medical conditions with high rate of cell turnover
• Rapid onset of pain
• Joint stiffness
• Foot-joint distribution
• Swelling, erythema, pain
• Tophi

Question 3

What foods and beverages can precipitate gout?

Answer 3

High-purine foods and beverages:

• Organ meat
• seafood
• Sweetened Beverages
• Fructose
• Ethanol
• Beer

Question 4

What medication can cause gout?

Answer 4

Thiazide and loop diuretics
Cyclosporins
Aspirin

Question 5

What is Tophi?

Answer 5

Nodules created by monosodium urate crystals in a matrix of lipids, proteins, and monopolysaccharides

Question 6

What is the uremic goal for a normal person?

Answer 6

< 6 mg/dL and to decrease attacks

Question 7

What is the uremic goal for a person with increased risk factors?

Answer 7

<5 mg/dL

Question 8

What joint is most often affected?

Answer 8

Big toe

Question 9

What is the normal short-term treatment approach?

Answer 9

NSAIDs
Antigout drugs
corticosteroids

Question 10

How do NSAIDs aid in gout treatment?

Answer 10

Inflammatory response:
• Urate crystal formation in the joint space –> destruction of the cell membrane –> release of chemical mediators by enzymes –> inflammation

Question 11

Indomethacin:

MOA
Dose
Precautions/Cautions

Answer 11

Indomethacin:
MOA: Anti-inflammatory
Dose: 50 mg PO TID
Precautions/Cautions: 
  -- Take with food
  -- Same precautions as other NSAIDs
  --Caution with depression/psychiatric disorders

Question 12

Allopurinol MOA

Dosing

Answer 12

Acts directly on purine metabolism

Allopurinol:start100mgQD,increaseby100 mg/day qwk until uric acid level <6 mg/dL; max 800 mg QD (for doses >300 mg divide BID–QID); give with food

Question 13

Febuxostat (Uloric) MOA:

Dosing

Answer 13

Potent and selective inhibitor of xanthine oxidase –> reduces the formation of xanthine and uric acid

Febuxostat(Uloric):start40mgQD,may increase to 80 mg QD if uric acid level >6 mg/dL after 2 weeks (can take with NSAID or colchicine with flare)

Question 14

Colchicine (Colcrys) MOA:

Dosing

Answer 14

Decreases deposition of uric acid and reduces phagocytesà decreased inflammation
• Metabolized in liver and excreted in kidneys

Colchicine(Colcrys):start1.2mgPOx1,then0.6 mg 1 hr later x 1; max 1.8 mg total dose/attack

Question 15

Allopurinol Side Effects

Answer 15

Diarrhea
N/V
Abdominal pain
Rash
Pruritis
Elevated ALT/AST, ALK, PHOS

*Rare: Aplastic anemia, hepatic toxicity, bone marrow suppression

Question 16

Febuxostat Side Effects

Answer 16

Diarrhea
N/V
Abdominal pain
Elevated ALT/AST
Headache

*Rare: hepatic toxicity, Steven Johnson syndrome, Rabdo, Interstitial nephritis

Question 17

Colchicine Side Effects

Answer 17

Diarrhea
N/V
Cramping/Abdominal pain

*Rare: Hepatic necrosis, Acute renal failure, DIC, Death

Question 18

What are some cautions with anti-gout drugs?

Answer 18

Caution with (severe) renal and hepatic impairment

Question 19

What drug are some drug interaction to be concerned about when prescribing Allopurinol?

Answer 19

Allopurinol inhibits probenecid and Anticoagulants.

Allopurinol increases hepatic iron concentrations

Question 20

What labs need to monitored with Allopurinol?

Answer 20

Baseline and Monitor LFT’s

Test those of Asian descent for HLA-B5801 allele before starting

Question 21

What kind of medication is Probenecid?

Answer 21

Uricosuric agent

Question 22

Probenecid MOA

Answer 22

Increases renal excretion of uric acid and decreases serum uric acid levels

Question 23

Is probenecid used for acute attacks?

Answer 23

NO, initiate 2-3 weeks after acute attack

Question 24

Probenecid Side Effects

Answer 24

Nausea/vomiting
Rash and pruritus
Headache
Fever
Nephrotic syndrome
*Aplastic or hemolytic anemia
*Hepatic necrosis

Question 25

Probenecid Contraindication/cautions

Answer 25

Underlying or recent h/o PUD
Uric Acid Nephrolithiasis
Acute gout attack
CrCl <50
Avoid ASA or Salicylates --> Mutually antagonistic with Probenecid
Sulfa --> allergy/sensitivity

Question 26

Probenecid Dosage

Answer 26

Probenecid: start 250 mg PO BID x 7 days;
max 2–3 g/day
(CrCl <50 ineffective; avoid use with PCN when known renal impairment)
Take with food

Question 27

What pregnancy Category is Probenecid?

Answer 27

Category B

Unknown in lactation

Question 28

What pregnancy Category is Allopurinol?

Answer 28

Category C

Found in breast milk

Question 29

What pregnancy Category is Colchicine (orally)

Answer 29

Category C

Unknown in lactation

Question 30

What pregnancy Category is Febuxostat

Answer 30

Category C

Unknown in lactation

Question 31

What pregnancy Category is Colchicine (parenterally)

Answer 31

Category D

Question 32

What should be used in patients with renal calculi?

Answer 32

Allopurinol

Question 33

What monitoring should be completed with anti-gout and uricosuric agents?

Answer 33

• Monitoring
– Serum uric acid levels 
      Men <7 mg/dL; Premenopausal woman <6 mg/dL
       Every 2-5 weeks initially, every 6 months once 
           stable
– LFTs, 
--BUN/Cr with allopurinol
– CBC with probenecid

Question 34

How should acute attacks be managed?

Answer 34

Continue prophylactic med with addition of colchicine

Question 35

What signs and symptoms should a patient stop taking the med call provider?

Answer 35

A sore throat, fatigue, jaundice, unusual bruising/bleeding, muscle weakness/pain

Question 36

What lifestyle modifications can patients make to reduce gout attacks?

Answer 36

Lifestyle management: low-purine diet, low Na+, low Ca+, low ETOH, >3 liters/day of fluids

Question 37

How are corticosteroids used in gout attacks?

Answer 37

• Used for acute flares
• Burst or flare
• Same s/e profile and considerations when used in RA