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MJ- P2 E2 > Gout > Flashcards

Gout Flashcards

1
Q

T/F: All individuals with hyperuricemia will at some point develop a clinical event from urate crystal deposition

A

FALSE

Most individuals w/ hyperuricemia may never develop a clinical event from urate crystal deposition

(so don’t tx hyperuricemia if no h/o gout!)

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2
Q

Drugs active in gout inhibit what 2 things?

A
  1. Crystal phagocytosis
  2. PMN and macrophage release of inflammatory mediators
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3
Q

Is it more common for a person to have overproduction or underexcretion of uric acid?

A

Underexcretion

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4
Q

Where is 2/3 of the daily uric acid production excreted?

A

In the urine

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5
Q

2/3 of the daily uric acid production is excreted in the urine, where is the remainder eliminated?

A

Through the GI tract after enzymatic degradation by colonic bacteria

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6
Q

The following are examples of _____ rich foods:

  • Bacon
  • Beef
  • Chicken
  • Mushrooms
  • etc
A

Purine rich foods

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7
Q

What is the definitive dx of gout?

A

tapping the joint and microscopic exam of uric acid crystals

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8
Q

In the absence of a history of gout, does asymptomatic hyperuricemia require treatment?

A

no

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9
Q

What is acute gout?

A

Attacks of joint inflammation

3-10 days

Usually affecting the 1st MTP

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10
Q

Which toe does acute gout most commonly affect?

(how many days, area MCly affected?)

A

1st MTP- Podagra “foot pain”

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11
Q

Chronic or acute gout?

  • Rheumatoid-like
  • Tophaceous Gout
A

Chronic gout

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12
Q

What type of urate is in the soft tissues and joints in Tophaceous gout?

A

Monosodium urate

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13
Q

What is non-pharmacological treatment for acute gout?

A

Local ice application

(most effective as adjunctive tx)

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14
Q

What are the 3 acute gout first line treatments?

A
  1. NSAIDs (Indomethacin, naproxen and Sulindac)
  2. Corticosteroids
  3. Colchicine
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15
Q

Within how many hours of acute gout attack onset should treatment (NSAIDs, colchicine, steroids) be taken and for how many days?

(red)

A

Within 24 hours

until complete resolution, ~5-8 days after initiating therapy

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16
Q

Mechanism of which acute gout med?

  • Inhibition of microtubule assembly decreases macrophage migration and phagocytosis
  • Inhibits leukotriene B4 decreasing inflammation
A

Colchicine

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17
Q

Acute Gout tx:

Colchicine must be used w/in ___ hrs of attack onset to be effective

(red)

A

36

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18
Q

What are the 3 ADEs of Colchicine?

(red)

A
  1. N/V/D
  2. Myelosuppression (rare)
  3. Neuromyopathy (reversible)
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19
Q

Dose adjustment of Colchicine is recommended when used with what 2 groups of meds?

(red)

A

selected CYP3A4 and P-glycoprotein inhibitors

(so don’t give w/ -azoles or -vir)

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20
Q

Colchicine inhibits renal tubular secretion of what med?

A

Methotrexate

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21
Q

When is intraarticular corticosteorid (TAC-Kenalog) administration acceptable in the tx of acute gout?

What meds should it be used in combo with?

A
  • When only 1 or 2 joints involved
  • Should be used in combo w/ NSAIDs, Colchicine or oral corticosteroids
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22
Q

What 3 meds can be used for tx of chronic gout?

A
  • Colchicine
  • Probenicid
  • Allopurinol, Febuxostat
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23
Q

Which med should be used for refractory cases of chronic gout?

A

Pegloticase (Biologic)

24
Q

What are the 2 xanthine oxidase inhibitors used to tx chronic gout?

A

Allopurinol

Febuxostat

25
Which chronic gout med currently only has an indication for hyperuricemia in malignancy
Rasburicase
26
What is the main side effect of Colchicine and is often difficult to tolerate?
Dose dependent **diarrhea**
27
What are the 3 anti-inflammatory regimens that are needed during the initiation of urate-lowering therapy (ULT)?
1. Colchicine OR 2. Low dose NSAIDs w/ PPI OR 3. Prednisone
28
**Anti-inflammatory** regimens (Colchicine, NSAIDs w/ PPI or prednisone) are required during the initiation of urate lowering therapy. ## Footnote **How long should they be continued?**
Continue at least **6 months** or **3-6 months after achieving target** serum uric acid
29
What are Xanthine osidase inhibitors (allopurinol/febuxostat) efficacious for?
prophylaxis of recurrent gout attacks in both **underexcreters and overproducers** of uric acid (red)
30
In what 4 for initiation of allopurinol or febuxostat?
* **2+ gout attacks** per year * presence of **1+ tophus** * **CKD** (stage 2 or worse) * history of **urolithiasis**
31
What is the goal serum urate concentration level?
**_\< 6mg/dL_** or \< 5 if signs of gout persist
32
What is the **first line** Urate Lowering Therapy? (red)
Xanthine Oxidase Inhibitor (**Allopurinol**)
33
MOA of which chronic gout med? * Active metabolite **_irreversibly_ inhibits xanthine oxidase** and **lowers production of uric acid**
**Allopurinol** | (Xanthine Oxidase Inhibitor)
34
When prescribing Allopurinol, what do you need to educate patients about? (red)
**_Acute Hypersensitivity syndrome_** (highest risk in first few months of therapy)
35
ADEs of which med? * Pruritis * rash * Elevated LFTs * **Acute Hypersensitivey Syndrome**
Allopurinol
36
Which 2 **high risk populations** should you consider **genetic testing** for due to increased concern for **Acute Hypersensitivity Syndrome** while taking **Allopurinol?** (red)
* •Koreans with CKD * •Han Chinese and Thai irrespective of renal function
37
Which Xanthine Oxidase Inhibitor is a **_reversible_** **inhibitor of xanthin**e but is very expensive?
Febuxostat
38
Febuxostat is contraindicated with what?
azathioprine
39
Febuxostat: * •No dose adjustments in patients with mild to moderate _____ or ____ impairment *
Renal or hepatic
40
What are the 4 ADEs of Febuxostat?
**_–Liver enzyme elevation_** –Nausea –Arthralgias –Rash
41
What are 2 things that you must **monitor** in a patient taking **Febuxostat** due to concern for **toxicity**?
* Liver Function tests * Renal function
42
T/F: Fubuxostat Can be used in both urate overproduction and urate under excretion
true
43
Febuxostat: * No dosage adjustment necessary for patients with \_\_\_\_\_\_\_renal dysfunction (creatinine clearance **\_\_\_\_–\_\_\_\_ m**L/min)
Mild to moderate 30-89
44
What are the 2 Uricosouric Therapy options (increase uric acid excretion)?
1. Probenecid 2. XOI + fenofibrate or losartan
45
For Probenecid, copious amounts of what is needed?
copious **wate**r consumption
46
What are the 2 instances Probenecid should not be used?
1. CC \< 50mL/min 2. h/o urolithiasis
47
What does the following Uricosouric Therapy do: ## Footnote **XOI + fenofibrate or losartan**
Augments uric acid excretion
48
Which patients is the following Uricosouric Therapy beneficial for: ## Footnote **XOI + fenofibrate or losartan**
Patients with other disorders
49
Which med is used for patients **_refractory_** to conventional therapies?
**Pegloticase** | (Biologic)
50
Which med should you consider prescribing in a patient with heavy disease burder w/ chronic **tophaceous** disease?
**Pegloticase** | (Biologic)
51
MOA of which med? * Recombinant porcine-like uricase which then **metabolizes uric acid to allantoin** * Lowers uric acid levels and reduces deposits of uric acid crystals
**Pegloticase** | (Biologic)
52
MOA of which med? * **Inhibits function of transporter proteins** involved in renal uric acid reabsorption (uric acid transporter 1-URAT1) and organic anion transporter 4 (OAT4) * Lowers serum uric acid levels and **increases renal clearance** and fractional excretion of uric acid
Lesinurad
53
Which med is reserved for patients with **hyperuricemia** a/w **gout** who do **not achieve target** serum uric acid levels with conventional therapies? (can be used in both overproducers or underproducers)
Lesinurad
54
Lesinurad must be used in combo w/ a ______ due to increased risk of ________ with monotherapy (know!)
Lesinurad must be used in combo w/ a **_Xanthine Oxidase Inhibitor (like Allopurinol)_** due to increased risk of **_Renal Failure_** with monotherapy
55
ADEs of which med? * Acute gout attack during treatment initiation * **Headache** * **GERD** * Major adverse cardiovascular observed - causal relationship has not been established * **Renal function toxicity**
Lesinurad
56
The following are o**ff-labeled** options, which are ______ inhibitors: * Anakinra * Canakinumab * Rilonacept
Interleukin-1 inhibitors
57
Do you initiate **monotherapy** or combo therapy if a patient is complaining of **severe pain** during an acute gout attack?
Use combo therapy (ex: colchicine + NSAID) (mild-moderate pain you could use monotherapy)

MJ- P2 E2 (19 decks)

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