Gout Flashcards
What xterizes gout?
Gout typically occurs in 1 joint, which is most often the metatarsophalangeal joint (MTP, the big toe)
Causes of gout?
Uric acid is produced as an end-product of purine metabolism
Once gout crystallizes in joints, results in severe, painful gout attack
When does gout typically strike?
After many years of persistent Hyperuricemia
Risk factors of gout?
Male sex
Obesity
Excessive alcohol consumption (particularly beer)
HTN
Chronic kidney dx
Lead intoxication
Advanced age
Meds that increase uric acid
What should pt avoid to reduce risk of recurrent gout attacks?
Organ meats
High-fructose corn syrup
Alcohol
What should pt be encouraged to reduce risk of recurrent gout attacks?
Low-fat dairy products
Vegetables
Hydration
Weight loss
Exercise
Meds with highest known risk to increase uric acid (there are others with possible risk or case reports)?
Diuretics (thiazides, loops)
Niacin
Aspirin, higher doses
Pyrazinamide
Cyclosporine
Tacrolimus
What increases purine
Diet
Alcohol
Purine leads to?
Xanthine
What enzyme converts Xanthine to Urate?
Xanthine oxidase
What inhibits Xanthine oxidase?
Allopurinol
Febuxostat
What enzyme converts Urate to Allantoin and Uric acid crystals?
Urate oxidase
What’s normal serum uric acid level?
2.0 - 7.2
Is asymptomatic Hyperuricemia treated?
No!
T/4 if given a case with elevated uric acid, don’t choose tx unless gout attack has occurred
What’s the goal of tx?
Treat acute attacks, prevent future flare-ups and reduce UA levels
T/F? Drugs used to treat an acute attack (colchine, NSAIDs, steroids) are diff than drugs used to prevent attacks?
T
First line tx for acute gout tx?
Colchine
NSAID
Systemic corticosteroids
Or combo of these agents
What can the first line tx be supplemented with?
Topical ice therapy
If a pt is already on (Allopurinol, Febuxostat) should they be interrupted during a gout attack?
No!
When should chronic prophylactic therapy be started?
In pts with >= 2 acute attacks/yr
In pts who have tophi
What’s first line agents for chronic gout prophylactic therapy?
Xanthine-oxidase (XO) inhibitors (Allopurinol or Fubuxostat)
How are Xanthine-oxidase (XO) inhibitors (Allopurinol or Fubuxostat) titrated? Why?
Slowly
To lower uric acid to < 5-6 mg/dL
List agents used in acute gout attack tx
Colchine
NSAIDs
Steroids
What’s the brand name of Colchine? (Acute gout attacks)
Colcrys
How to use Colchine (Colcrys)? (Acute gout attacks)
1.2mg orally (this is two 0.6mg tablets) followed by 0.6mg in 1hr (don’t exceed a total of 1.8mg)
Until the acute attack resolves
SEs of Colchicine (Colcrys)? (Acute gout attacks)
Nausea
Vomiting
Diarrhea
When is colchicine (Colcrys) recommended? (Acute gout attacks)
Only when tx is started within 36hrs of onset of sx
List NSAIDs agents used in acute gout attacks
Indomethacin (Indocin)
Naproxen (Naprosyn, others)
Sulindac (Clinoril)
Celecoxib (Celebrex) - off-label
What’s brand name of Indomethacin used in tx of Acute gout attacks?
Indocin
What’s brand name of Naproxen used in tx of Acute gout attacks?
Naprosyn
What’s brand name of Celecoxib used in tx of Acute gout attacks?
Celebrex
Which NSAIDs is used off-label in tx of Acute gout attacks?
Celecoxib (Celebrex)
In what grp of pts is NSAIDs CI wrt to acute gout attack tx?
Avoid use in severe renal dx
CVD risk (most with Celecoxib: Celebrex)
What’s the unique SE of indomethacin (Indocin)
Psychiatric SE including confusion, depression, psychosis
How can steroids used in acute gout attack tx be given?
PO, IM, IV, Intra-articular or via ACTH (adrenocorticotropic hormone) which triggers endogenous glucocorticoid secretion
List steroids agents used in acute gout attack?
Prednisone (PO)
Methylprednisolone (intra-articular; oral; IM)
Howz prednisone dosed?
0.5mg/kg/day for 5-10 days (no taper)
OR
0.5mg/ kg/day for 2 days, then taper to 5mg each day for 7-10 days
What’s xtics of Colchicine may be important to know for drug interactions?
Colchicine is a substrate of CYP 3A4 and efflux transporter P-glycoprotein (P-gp)
When is fatal toxicity a concern when using colchicine (Colcrys)?
When Colchine (3A4 substrate) is used with strong inhibitors e.g Clarithromycin
OR
Strong inhibitor of P-gp, such as cyclosporine
What the max dose of Colchine (Colcrys) if used with a moderate 3A4 inhibitor?
1.2mg (2 tablets)
When should colchicine be used?
At first sign of gout attack
Take 2 tabs immediately. U can use 1 more tab in 1 hr
When should the 2nd dose of colchicine NOT be taken?
If pt has upset stomach, nausea or diarrhea
How long after Colchicine should pt wait b4 initiating another tx for acute gout attacks?
At least 3 days
MOA of Xanthine oxidase (for prophylactic tx of gout)?
Block uric acid (UA) production
List chronic uric acid (UA) lowering drugs
Xanthine oxidase inhibitors (Allopurinol and Febuxostat)
Uricosuric (Probenecid and Colchicine-Probenecid)
Uricase (Pegloticase injection)
What should be used in addition to chronic UA therapy, when initiating chronic UA therapy? Why?
Colchicine at daily dose of 0.6mg once or twice daily
OR
NSAIDs for at least 6 months
To reduce the risk of acute flares when beginning UA-lowering acid therapy
List Xanthine Oxidase Inhibitor agents
Allopurinol (Zyloprim)
Febuxostat (Uloric)
What’s the brand name of Allopurinol (Xanthine Oxidase Inhibitors - used for chronic UA lowering)?
Zyloprim
What’s warnings associated with Allopurinol (Zyloprim)?
Hypersensitivity rxns including severe rash (SJS/TEN)
What’s the max starting dose of allopurinol (Zyloprim) in pts with CKD?
50mg daily
What’s the warning associated Febuxostat (Uloric) use?
Hepatotoxicity
List Uricosuric agents (chronic UA-lowering therapy)
Probenecid
Colchicine-Probenecid
What’s required before Uricosuric agent (Probenecid and Colchicine-Probenecid) is used?
Adequate renal fxn
What’s the agent under Uricase (chronic UA-lowering therapy)?
Pegloticase (Krystexxa)
When is Pegloticase (Krystexxa) used?
Refractory cases only
What’s the black box warning associated with Pegloticase (Krystexxa) use?
Anaphylactic rxn
What can be done to alleviate the black box warning ass with Pegloticase (Krystexxa) use?
Premedicate with antihistamines and corticosteroids
When do u d/c Pegloticase (Krystexxa)?
UA > 6mg/dL
SEs of Pegloticase (Krystexxa)?
Antibody formation
Gout flare
Infusion rxns
Nausea
Bruising
Urticaria
Erythema
Pruritus
What chronic UA-lowering drugs can’t Pegloticase (Krystexxa) be used with?
Allopurinol (Zyloprim)
Cockcroft-Gault Eqn?
(140-age) x body weight (kg)
Divided by
72 x SCr
What SE may a pt on short-course prednisone therapy experience?
Insomnia/spaciness
What’s gout?
A dx that usually presents with recurrent attacks of acute inflammatory arthritis
