Gout Flashcards by jennifer hunter

What xterizes gout?

Gout typically occurs in 1 joint, which is most often the metatarsophalangeal joint (MTP, the big toe)

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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

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When does gout typically strike?

After many years of persistent Hyperuricemia

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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

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What should pt avoid to reduce risk of recurrent gout attacks?

Organ meats

High-fructose corn syrup

Alcohol

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What should pt be encouraged to reduce risk of recurrent gout attacks?

Low-fat dairy products

Vegetables

Hydration

Weight loss

Exercise

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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

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What increases purine

Diet

Alcohol

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Purine leads to?

Xanthine

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What enzyme converts Xanthine to Urate?

Xanthine oxidase

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What inhibits Xanthine oxidase?

Allopurinol

Febuxostat

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What enzyme converts Urate to Allantoin and Uric acid crystals?

Urate oxidase

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What’s normal serum uric acid level?

2.0 - 7.2

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Is asymptomatic Hyperuricemia treated?

No!

T/4 if given a case with elevated uric acid, don’t choose tx unless gout attack has occurred

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What’s the goal of tx?

Treat acute attacks, prevent future flare-ups and reduce UA levels

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T/F? Drugs used to treat an acute attack (colchine, NSAIDs, steroids) are diff than drugs used to prevent attacks?

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First line tx for acute gout tx?

Colchine

NSAID

Systemic corticosteroids

Or combo of these agents

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What can the first line tx be supplemented with?

Topical ice therapy

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If a pt is already on (Allopurinol, Febuxostat) should they be interrupted during a gout attack?

No!

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When should chronic prophylactic therapy be started?

In pts with >= 2 acute attacks/yr

In pts who have tophi

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What’s first line agents for chronic gout prophylactic therapy?

Xanthine-oxidase (XO) inhibitors (Allopurinol or Fubuxostat)

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How are Xanthine-oxidase (XO) inhibitors (Allopurinol or Fubuxostat) titrated? Why?

Slowly

To lower uric acid to < 5-6 mg/dL

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List agents used in acute gout attack tx

Colchine

NSAIDs

Steroids

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What’s the brand name of Colchine? (Acute gout attacks)

Colcrys

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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