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Pharmacotherapy > Gout > Flashcards

Gout Flashcards

1
Q

Which patient group are likely affected by gout

A

Older adults

Obese adults

Male

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2
Q

What is gout

A

Overproduction or underexcretion of Uric acid

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3
Q

What is considered hyperuricemia for male and female

A

Male serum urate > 7 mg/dL

Female serum urate > 6 mg/dL

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4
Q

What is the pathophysiology for gout

A

Hyperuricemia

Deposition of monosodium urate crystals causing inflammation

Development of tophi

Nephrolithiasis, nephropathy (kidney stone or damage)

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5
Q

What are the medication that increase serum urate/hyperuricemia

A

Thiazides

Cytotoxic agents

Cyclosporine

Niacin

Low-dose aspirin

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6
Q

Acute gout affects how many joint

A

Monoanticular usually the big toe joint

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7
Q

What are the sx of acute gout

A

Joint pain, erythema, swelling, warmth

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8
Q

Atypical presentation of acute gout is seen in which patient group and is sometimes confused with what pathology

A

Elderly patients

RA or OA

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9
Q

What type of gout is known as podagra

A

Classic gout

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10
Q

How is acute gout assessed

A

Sx and hx

Aspiration of synovial fluid to identify crystals

Serum uric and: which can be low or normal

Radiograph

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11
Q

The 2020 American college of rheumatology guideline classifies the management of gout under what two categories

A

Strong

Conditional

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12
Q

What is the strong recommendation for acute gout management

A

Low dose colchicine

NSAIDs

Glucocorticoids

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13
Q

What are the conditional recommendation for acute gout management

A

Topical ice

IL-1 inhibitor when all else fails

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14
Q

A gout pain scale of ≤4 is considered

A

Mild

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15
Q

A gout pain scale of 5-6 is considered

A

Moderate

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16
Q

A gout pain scale of ≥ 7 is considered

A

Severe

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17
Q

A duration of a gout attack since < 12hours after onset is considered

A

Early

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18
Q

A duration of a gout attack since 12-36 hours after onset is considered

A

Well-Established

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19
Q

A duration of gout attack > 36 hours since onset is considered

A

Late

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20
Q

How is the extent of gout attack classified

A

Based on number of joints affected

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21
Q

Extent of gout attack classifications

A

One or a few small joint

1 or 2 large joints (ankle, knee, wrist, elbow, hip, shoulder)

Polyarticular ( 4 or more joints involving more than one region or 3 separate large joint )

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22
Q

Acute gout attacks should be treated with what?

A

Pharmacologic therapy

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23
Q

To provide optimal care, pharmacologic therapy should be initiated when

A

With 24 hours of onset

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24
Q

Should ongoing Uric lowering therapy be interrupted during an acute gout attack

A

No

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25
Q

What is the first thing when managing acute gout attacks

A

Assess severity

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26
Q

If severity is mild or moderate pain involving 1 or 2 small or large joint what should be initiated

A

Monotherapy and supplement with topical ice if needed

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27
Q

What are the monotherapy

A

Colchicine

Systemic corticosteroids

NSAIDs or cox-inhibitors

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28
Q

What if assessing severity pain is severe involving polyarticular or multiple large joints what kind of therapy should be initiated

A

Initial combination therapy

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29
Q

What if after initiating monotherapy there is inadequate response what should you do

A

Consider alternate monotherapy

or

Try add-on combination therapy

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30
Q

What if after switching to a different monotherapies or trying add-on combination there is still inadequate response what should you do?

A

Consider off-label therapies in development

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31
Q

What is meant by inadequate response

A

< 20% improvement in pain score within < 24 hours of therapy initiation

Or

< 50% pain reduction at ≥ 24 hours of therapy initiation

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32
Q

What do you when patient is reporting well to monotherapies

A

Initiate patient education on:

Diet and lifestyle triggers and role of prompt self-treatment of subsequent attacks

Consider indications for ULT or adjustment of ongoing ULT treatment

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33
Q

What NSAIDs are considered for acute gout attacks

A

Naproxen

Indomethacin

Sulindac

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34
Q

What is the duration of therapy with NSAIDs

A

5-7 days

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35
Q

How is naproxen dosed for acute gout attacks

A

750 mg initially then 250mg every 8hours

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36
Q

How is indomethacin dosed for acute gout attacks

A

50 mg TID

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37
Q

How is sulindac dosed for acute gout attacks

A

200 mg BID

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38
Q

When using NSAIDs as therapies what should you be mindful of

A

GERD, GI events or Hypertension

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39
Q

What is first line recommendation

A

Colchicine

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40
Q

Colchicine MOA

A

Inhibits polymerization of beta-tubulin into microtubule prevention activation and migration of neutrophils

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41
Q

When is colchicine initiated

A

Within 36 hours of sx onset

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42
Q

For whom should dose be adjusted for and contraindicated

A

Renal/hepatic impairment

P-gp or CYP3A4 inhibitors

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43
Q

What are the ADRs of colchicine

A

GI

Myopathy

Myelosuppression

44
Q

How is colchicine dosed

A

1.2 mg followed by 0.6mg 1 hour later

45
Q

If a patient is having a gout attack but have never been on colchine prophylaxis

Or

Has not received colchicine within the last 14 days what should be done

A

Start 1.2mg followed by 0.6 mg an hour later and start prophylaxis dosing at 12 hours or later until gout resolves.

46
Q

What if your patient has received colchience within the last 14 days and is having acute gout attack what should be done

A

Choose NSAID or corticosteroid

47
Q

if patient is on NPO what corticosteroid dosage form should be used

A

IV, IM or IA

48
Q

For acute gout affecting 1-2 larger joints how is corticosteroids used

A

Consider intra-Articular corticosteroids

49
Q

For all cases of gout how is corticosteroids initiated

A

0.5mg/kg of prednisone perday for 5-10 days at full dose

Or

2-5 days at full dose and gradually taper off for 7-10 days and stop

Or

Methylprednisolone dose pack

50
Q

How is intramuscular corticosteroid dosed for acute your

A

Triamcinolone 60 mg followed by oral prednisone

51
Q

When gout attack is considered severe or patient is considered inadequate response to monotherapy what is the approved combination therapy that can be initiated

A

Colchicine + NSAIDs

Oral corticosteroids + colchicine

Intrarticular steroid + any other systemic options

52
Q

What combination therapy should be avoided

A

NSAID + systemic corticosteroid due to GI toxicity

53
Q

Off label IL-1 inhibitors

A

Anakinra

Canakinumab

54
Q

Off-label herbal

A

Cherries extract

Dairy protein

55
Q

What lifestyle management can be used for chronic management of gout symptoms

A

Limit alcohol intake

Limit purine intake

Limit high fructose com syrup intake

Loose weight of obese or overweight

Do not use vitamin C supplementation

56
Q

When is pharmacologic ULT strongly recommended for chronic management of gout

A

≥ 1 subcutaneous tophi

Radiography damage attributed to gout

Frequent gout flares

57
Q

When is pharmacologic ULT conditionally recommended for chronic management of gout

A

> 1 flare but have infrequent flare

Or

First flare with:

Moderate to severe CKD

Serum Urate > 9 mg/dl

Urolithiasis (kidney stone)

58
Q

Pharmacologic ULT is conditionally recommended against for

A

First gout flare

Asymptomatic hyperuricemia

59
Q

What are the ULT

A

Allopurinol

Febuxostat

Probenecid

Leisured

Pegloticase

60
Q

Which ULT’s are Xanthine oxidase inhibitors

A

Allopurinol

Febuxostat

61
Q

Which UTL’s are uricosuric agents

A

Probenecid

Lesinurad

62
Q

What is first line ULT

A

Allopurinol

63
Q

What test should select population (South-Asian, African American) do to identify risk of developing serious side effects of

A

HLA-B*5801

64
Q

What is the daily starting dose of allopurinol

A

≤ 100 mg

65
Q

For Patient with CKD or worse renal function what is the starting allopurinol dose

A

50 mg

66
Q

Allopurinol ADR

A

Rash

Pruritus

Allopurinol hypersensitivity syndrome

Elevated hepatic transaminases

67
Q

Can > 300 mg be used in renal impairment if accompanied by patient education and monitoring

A

Yes

68
Q

Febuxostat initial dosing

A

40 mg once daily

69
Q

Caution when dosing febuxostant

A

Severe renal/hepatic impairment

Previous allopurinol hypersensitivity

70
Q

Who is febuxostat contraindicated (BBW) and why

A

Cardiovascular disease due to increased risk of death

71
Q

Febuxostat ADR

A

Rash,

liver function abnormalities,

nausea,

arthralgia,

hypersensitivity,

gout flare

72
Q

Probenecid MOA

A

Inhibit reabsorption of uric acid from PCT

73
Q

Probenecid contraindication

A

Urolithiasis History

74
Q

Probenecid initial dosing

A

250mg BID for a week then 500 mg BID

75
Q

For which patient is probenecid not recommended as first line

A

CrCl < 50ml/min

76
Q

Probenecid ADR

A

Urolithiasis

GI upset

77
Q

Pegloticase MOA

A

Pegylated recombinant uricase that converts Uric acid to allantoin

78
Q

When is pegloticase used

A

In severe disease. never first line of therapy

79
Q

Dosage Form of pegloticase

A

IV only

80
Q

What should be done before pegloticase administration

A

Pretreat with antihistamine or corticosteroids

81
Q

Pegloticase dosing

A

8 mg IV every 2 weeks

82
Q

Contradiction for pegloticase

A

G6PD deficiency

83
Q

Pegloticase ADR

A

Anaphylaxis

Infusion reaction

84
Q

What is the con of pegloticase

A

Infusion takes > 2 hours

Cost

Infusion related reactions

85
Q

What are the two miscellaneous Urate lowering agents

A

Fenofibrate

Losartan

86
Q

How does fenofibrate help with gout

A

Increasing clearance of hypoxanthine and xanthine

87
Q

During the initiation of fenofibrate did patient indicate gout flare

A

No

88
Q

What about fenofibrate is conditionally recommended against

A

Addition or switching as risks outweigh potential benefit

89
Q

How does losartan help with gout

A

By inhibiting renal reabsorption of uric acid and increasing its excretion and alkalanizing urine

90
Q

Why is losartan unique with this application

A

Its mechanism of action is not an ARB class effect

91
Q

When is losartan conditionally recommended

A

To use when feasible

92
Q

During the initiation of a ULT was is the target serum uric acid level

A

< 6 mg/dL

93
Q

What is Strongly Recommended during initiation of ULT

A

First line allopurinol

CKD stage >3 start low dose XOI therapy

94
Q

What is conditionally recommended during initiation of ULT

A

Low dose probenecid during gout flare instead of after resolution

95
Q

During initiation of ULT what is Strongly Recommended against

A

Using pegloticase as first line therapy

96
Q

During initiation of ULT what is strongly recommended as prophylaxis

A

Concomitant administration of either colchicine, NSAID, prednisone continued for 3-6 months

97
Q

In management of ULT what general consideration is conditionally recommended

A

Intervention led by nurses or pharmacist should be included

ULT use can be continued indefinitely

98
Q

When considering switching to alternate therapy what is conditionally recommended

A

It is conditionally recommended to Switch to different XOI if:

Serum Uric acid is persistently high

Continued frequent gout flare in greater than 2 years

Unresolved subcutaneous tophi

99
Q

When considering switching to alternate therapy what is strongly recommended against

A

It is Strongly Recommended against switching patient to pegloticase for whom other ULT has failed but have infrequent gout flare in less than two years with no tophi

100
Q

What are the steps to performing switches or making changes to gout therapy management

A

Before any switch as made, titrate x01 formaxionum appropriate close and measure uric acid every 2-5 weeks during titration

If not at goal add uricosuric to XOI titrating both at maximum appropriate dose

Last alternative is pegloticase use

101
Q

If patient is at goal, how often should serum Uric acid be monitored

A

Every 6 months

102
Q

What is colchicine drug interactions

A

CYP3A4 inhibitors

PGP inhibitors.

103
Q

What is the interaction of allopurinol and febuxostat

A

They increase the concentration of warfarin, theophylline, azathioprine

104
Q

What is the drug interaction with probenecid

A

Low dose aspirin decreases its urocosuric effect

It inhibits the tubular secretion of penicillin, cephalosporin, rifampin, methotrexate

105
Q

Patient centered care focuses on what aspects

A

Renal insufficiency

GI disease

Congestive heart failure

Hypertension

Polypharmacy

Financial Limitations

Pharmacotherapy (12 decks)

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