Gout Flashcards
presentation of gout
sudden extreme pain redness systemic - fever and chills warmth
modifiable risk factors
hyperuricemia hypertension obesity diabetes alcohol consumption high purine intake drugs
non modifiable risk factors
CKD
male gender
age
family history
hyperuruicemia uric acid levels in males
> 480umol/L
hyperuricemia uric acid levels in females and why are they lower than males
> 420umol/L
estrogen promotes excretion of uric acid
after menopause closer to male levels
uric acid production
breakdown of dna into purines that degrade into uric acid
dietary sources
high protein meat
fish
beer
causes of uric acid overproduction
diet - only plays a role if secondary metabolic problem
tissue breakdown
metabolic derangement
cancer blast cells have a high death rate do lots of dna being degraded
causes of uric acid underexcretion
renal abnormalities
why does poor kidney function affect uric acid levels
lots of movement in and out of the kidney
kidney excretes the uric acid
why does gout occur in peripheral sites
solubility decreases as the temp of the tissue decreases
as get further from the body the temp is decreased
things you need for gout to occur
high uric acid levels
colder temp of the body
joint that has been damaged in some way
how fast does gout occur
over night
how long for recovery if left untreated
3-14 days
joint affected in gout
toe instep ankle heel knee wrist finger elbow
precipitating factors for an attack
stress or trauma alcohol infection surgery rapid lowering of serum uric acid**** drugs that increase uric acid
issues with measuring serum uric acid level
will be normal bc the uric acid is redistributed into the joint and draws down the plasma level even tho its normally high
labs to get
serum uric acid level
creatinine and BUN
if other sx present that may relate to cancer get a CBC
chronic complications of gout
nephrolithiasis (uric acid stones in kidneys)
gouty nephropathy acute or chronic
tophi formation - fluid accumulation
what is chronic tophaceous gout
chronic urate deposits in catilage, tendons, and synovial membranes
occur when intercritical periods no longer pain free
intermittent acute gout for 10 years
treatment goals
relieve pain and inflammation within 48hrs of an attack
complete resolution of symptoms in 7 days
reduce uric acid levels to below 360umoléL
prevvent recurent attacks
prevent chronic complications
drugs for acute gouty arthritis
nsaids
cox2 inhibitor
colchicine
corticosteroids
short term prophylactic drugs
colchicine
nsaid low dose
long term prophylactic drugs
allopurinol
febuxostat
drugs that can cause hyperuricemia
diuretics (thiazide) salicylates theophylline glucocorticoids ketoconazole cyclosporin tacrolimus
ibuprofen dose
600 QID
naproxen dose
750 then 500 BID
indomethacin dose
50 TID
celceoxib dose
400 BID x 2days then 200 BID
initiation and stoping for nsaids in acute flare
use max dose at first sign of attack
lower dose as symptoms resolve
leave on until joint pain has resolved totally for 48hrs (10 days )
other prescriptions to give with nsaids
PPI for gut protection
more for next acute attack
colchicine drug interactions
cyo 2A4 inhibitors: diltiazem, verapamil, itraconazole, fluconazole, clarithromycin
statins and fibrates increase myalgia
colchicine dosing acute flare
1.2mg followed by 0.6mg in one hour
if tkaing prophylaxis just stop during treatment and resume in 12 hours
prednisone dosing acute
20-40mgéday for 4 days then taper over 1-2 weeks
pain relief in 12-48hrs
how to determine whether to use prophylactic therapy
serum urate concentration after attack has resolved
short term prophylaxis in patients with no tophi and normal or slightly elevated uric acid levels
colchicine 0.6mg BID
low dose NSAID
when to stop short term prophylaxis
uric acid normal and patient symptoms free for 6 months
when would you consider urate lowering therapy
recurrent attack, arthropathy, xray chages
tophi
gout with CKD
recurring renal stones
need for ongoing diuretic treatment after first attack
BP lowering therapies to use instead of hydrochlorothiazide, beta blockers, ACEI
CCB
losartan
goal of urate lowering therapy
<360umol/L
allopurinol MOA
blocks conversion of hypoxanthine to xanthine then uric acid
what is allopurinol hypersensitivity syndrome
isolated rash
severe cutaneous reactions, fever, eosinophilia, leukocytosis, renal involvement and hepatitis
risk factors for allopurinol hypersensitivity syndromr
recent onset of therapu
CKD
thiazides
initiating urate lowering therapy (prophylaxis)
start with rpophylactic therapy for the first 6 months
colchicine 0.6mg BID if crcl>50
or low dose nsaid naproxen 250 BID
when to start allopurinol
3 weeks after resolution of acute attack
initiat prophylactics 2 weeks before start
dosing of allopurinol
100mg OD (50 if <50crcl) titrate up 100mg every month until target of <360 dose beyond 300mg/day if needed
do you dicontinue allopurinol in acute flares
no
avoid combo of allopurinol or febuoxstat and
azathioprine
6 MP
block thier secretion adn get serious toxicity
febuxostat MOA
potent non purine selective inhibitor of xanthine oxidase
febuxostat doseing
40mg daily
titrate to 80mg after 2 weeks if serum >360
no dose adjustment in crcl>30
safe in moderate hepatic impaiement
when would you use febuxostat
allergic to allopurinol
also continue prophylaxis for 6 months withthis
non pharms
drink dairy?
vit c?
comfortable shoes
reduce alcohol
