Gout Flashcards
Which patient group are likely affected by gout
Older adults
Obese adults
Male
What is gout
Overproduction or underexcretion of Uric acid
What is considered hyperuricemia for male and female
Male serum urate > 7 mg/dL
Female serum urate > 6 mg/dL
What is the pathophysiology for gout
Hyperuricemia
Deposition of monosodium urate crystals causing inflammation
Development of tophi
Nephrolithiasis, nephropathy (kidney stone or damage)
What are the medication that increase serum urate/hyperuricemia
Thiazides
Cytotoxic agents
Cyclosporine
Niacin
Low-dose aspirin
Acute gout affects how many joint
Monoanticular usually the big toe joint
What are the sx of acute gout
Joint pain, erythema, swelling, warmth
Atypical presentation of acute gout is seen in which patient group and is sometimes confused with what pathology
Elderly patients
RA or OA
What type of gout is known as podagra
Classic gout
How is acute gout assessed
Sx and hx
Aspiration of synovial fluid to identify crystals
Serum uric and: which can be low or normal
Radiograph
The 2020 American college of rheumatology guideline classifies the management of gout under what two categories
Strong
Conditional
What is the strong recommendation for acute gout management
Low dose colchicine
NSAIDs
Glucocorticoids
What are the conditional recommendation for acute gout management
Topical ice
IL-1 inhibitor when all else fails
A gout pain scale of ≤4 is considered
Mild
A gout pain scale of 5-6 is considered
Moderate
A gout pain scale of ≥ 7 is considered
Severe
A duration of a gout attack since < 12hours after onset is considered
Early
A duration of a gout attack since 12-36 hours after onset is considered
Well-Established
A duration of gout attack > 36 hours since onset is considered
Late
How is the extent of gout attack classified
Based on number of joints affected
Extent of gout attack classifications
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 )
Acute gout attacks should be treated with what?
Pharmacologic therapy
To provide optimal care, pharmacologic therapy should be initiated when
With 24 hours of onset
Should ongoing Uric lowering therapy be interrupted during an acute gout attack
No
What is the first thing when managing acute gout attacks
Assess severity
If severity is mild or moderate pain involving 1 or 2 small or large joint what should be initiated
Monotherapy and supplement with topical ice if needed
What are the monotherapy
Colchicine
Systemic corticosteroids
NSAIDs or cox-inhibitors
What if assessing severity pain is severe involving polyarticular or multiple large joints what kind of therapy should be initiated
Initial combination therapy
What if after initiating monotherapy there is inadequate response what should you do
Consider alternate monotherapy
or
Try add-on combination therapy
What if after switching to a different monotherapies or trying add-on combination there is still inadequate response what should you do?
Consider off-label therapies in development
What is meant by inadequate response
< 20% improvement in pain score within < 24 hours of therapy initiation
Or
< 50% pain reduction at ≥ 24 hours of therapy initiation
What do you when patient is reporting well to monotherapies
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
What NSAIDs are considered for acute gout attacks
Naproxen
Indomethacin
Sulindac
What is the duration of therapy with NSAIDs
5-7 days
How is naproxen dosed for acute gout attacks
750 mg initially then 250mg every 8hours
How is indomethacin dosed for acute gout attacks
50 mg TID
How is sulindac dosed for acute gout attacks
200 mg BID
When using NSAIDs as therapies what should you be mindful of
GERD, GI events or Hypertension
What is first line recommendation
Colchicine
Colchicine MOA
Inhibits polymerization of beta-tubulin into microtubule prevention activation and migration of neutrophils
When is colchicine initiated
Within 36 hours of sx onset
For whom should dose be adjusted for and contraindicated
Renal/hepatic impairment
P-gp or CYP3A4 inhibitors
What are the ADRs of colchicine
GI
Myopathy
Myelosuppression
How is colchicine dosed
1.2 mg followed by 0.6mg 1 hour later
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
Start 1.2mg followed by 0.6 mg an hour later and start prophylaxis dosing at 12 hours or later until gout resolves.
What if your patient has received colchience within the last 14 days and is having acute gout attack what should be done
Choose NSAID or corticosteroid
if patient is on NPO what corticosteroid dosage form should be used
IV, IM or IA
For acute gout affecting 1-2 larger joints how is corticosteroids used
Consider intra-Articular corticosteroids
For all cases of gout how is corticosteroids initiated
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
How is intramuscular corticosteroid dosed for acute your
Triamcinolone 60 mg followed by oral prednisone
When gout attack is considered severe or patient is considered inadequate response to monotherapy what is the approved combination therapy that can be initiated
Colchicine + NSAIDs
Oral corticosteroids + colchicine
Intrarticular steroid + any other systemic options
What combination therapy should be avoided
NSAID + systemic corticosteroid due to GI toxicity
Off label IL-1 inhibitors
Anakinra
Canakinumab
Off-label herbal
Cherries extract
Dairy protein
What lifestyle management can be used for chronic management of gout symptoms
Limit alcohol intake
Limit purine intake
Limit high fructose com syrup intake
Loose weight of obese or overweight
Do not use vitamin C supplementation
When is pharmacologic ULT strongly recommended for chronic management of gout
≥ 1 subcutaneous tophi
Radiography damage attributed to gout
Frequent gout flares
When is pharmacologic ULT conditionally recommended for chronic management of gout
> 1 flare but have infrequent flare
Or
First flare with:
Moderate to severe CKD
Serum Urate > 9 mg/dl
Urolithiasis (kidney stone)
Pharmacologic ULT is conditionally recommended against for
First gout flare
Asymptomatic hyperuricemia
What are the ULT
Allopurinol
Febuxostat
Probenecid
Leisured
Pegloticase
Which ULT’s are Xanthine oxidase inhibitors
Allopurinol
Febuxostat
Which UTL’s are uricosuric agents
Probenecid
Lesinurad
What is first line ULT
Allopurinol
What test should select population (South-Asian, African American) do to identify risk of developing serious side effects of
HLA-B*5801
What is the daily starting dose of allopurinol
≤ 100 mg
For Patient with CKD or worse renal function what is the starting allopurinol dose
50 mg
Allopurinol ADR
Rash
Pruritus
Allopurinol hypersensitivity syndrome
Elevated hepatic transaminases
Can > 300 mg be used in renal impairment if accompanied by patient education and monitoring
Yes
Febuxostat initial dosing
40 mg once daily
Caution when dosing febuxostant
Severe renal/hepatic impairment
Previous allopurinol hypersensitivity
Who is febuxostat contraindicated (BBW) and why
Cardiovascular disease due to increased risk of death
Febuxostat ADR
Rash,
liver function abnormalities,
nausea,
arthralgia,
hypersensitivity,
gout flare
Probenecid MOA
Inhibit reabsorption of uric acid from PCT
Probenecid contraindication
Urolithiasis History
Probenecid initial dosing
250mg BID for a week then 500 mg BID
For which patient is probenecid not recommended as first line
CrCl < 50ml/min
Probenecid ADR
Urolithiasis
GI upset
Pegloticase MOA
Pegylated recombinant uricase that converts Uric acid to allantoin
When is pegloticase used
In severe disease. never first line of therapy
Dosage Form of pegloticase
IV only
What should be done before pegloticase administration
Pretreat with antihistamine or corticosteroids
Pegloticase dosing
8 mg IV every 2 weeks
Contradiction for pegloticase
G6PD deficiency
Pegloticase ADR
Anaphylaxis
Infusion reaction
What is the con of pegloticase
Infusion takes > 2 hours
Cost
Infusion related reactions
What are the two miscellaneous Urate lowering agents
Fenofibrate
Losartan
How does fenofibrate help with gout
Increasing clearance of hypoxanthine and xanthine
During the initiation of fenofibrate did patient indicate gout flare
No
What about fenofibrate is conditionally recommended against
Addition or switching as risks outweigh potential benefit
How does losartan help with gout
By inhibiting renal reabsorption of uric acid and increasing its excretion and alkalanizing urine
Why is losartan unique with this application
Its mechanism of action is not an ARB class effect
When is losartan conditionally recommended
To use when feasible
During the initiation of a ULT was is the target serum uric acid level
< 6 mg/dL
What is Strongly Recommended during initiation of ULT
First line allopurinol
CKD stage >3 start low dose XOI therapy
What is conditionally recommended during initiation of ULT
Low dose probenecid during gout flare instead of after resolution
During initiation of ULT what is Strongly Recommended against
Using pegloticase as first line therapy
During initiation of ULT what is strongly recommended as prophylaxis
Concomitant administration of either colchicine, NSAID, prednisone continued for 3-6 months
In management of ULT what general consideration is conditionally recommended
Intervention led by nurses or pharmacist should be included
ULT use can be continued indefinitely
When considering switching to alternate therapy what is conditionally recommended
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
When considering switching to alternate therapy what is strongly recommended against
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
What are the steps to performing switches or making changes to gout therapy management
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
If patient is at goal, how often should serum Uric acid be monitored
Every 6 months
What is colchicine drug interactions
CYP3A4 inhibitors
PGP inhibitors.
What is the interaction of allopurinol and febuxostat
They increase the concentration of warfarin, theophylline, azathioprine
What is the drug interaction with probenecid
Low dose aspirin decreases its urocosuric effect
It inhibits the tubular secretion of penicillin, cephalosporin, rifampin, methotrexate
Patient centered care focuses on what aspects
Renal insufficiency
GI disease
Congestive heart failure
Hypertension
Polypharmacy
Financial Limitations
