Gout Flashcards
Gout characterized by
Characterized biochemically by extracellular fluid urate saturation
Hyperuricemia – serum > 6.8 mg/DL
Gout is not just a
Not just a bone and joint issue
gout can cause
Increased hypertension (HTN) and cardiovascular (CV) risks associated with higher uric acid level Dietary Approaches to Stop Hypertension (DASH) diet not only helps in heart disease but also gout
old gout diets ar
Old gout diets not supported by evidence
gout what is key
Fluid intake is key
Gout managment
Acute management of gout flare-ups
Systemic and intra-articualar glucocorticoids, NSAIDs, and colchicine
Prevention of re-current gout flares and damage to joints and other tissues
Urate-lower drugs
Gout - drug examples
Colchicine and Probenecid, pegloticase, and lesinurad impact uric acid excretion (probenecid) or change it into inert substances
Colchicine does not
Does not impact purine metabolism
Colchicine major issue
Major issue of impacting granulocytes, but this does reduce deposits of uric formation
Colchicine is
Is pain med, but not an analgesic
Is anti-inflammatory
Colchicine mostly used
used as prophylactic or during acute attack
Probenecid, pegloticase, and lesinurad impact uric acid excretion (probenecid) or change it into inert substances
Deposits are
reduced and deposition retarded
NOT monotherapy drugs
Xanthine Oxidase - Uses on
Uses on patients with gout
To inhibit inflammation
Prevent synthesis of uric acid
Must not disrupt the biosynthesis of vital purines
Xanthine Oxidase do not need
for inflammatory agents (indocin) and steroids (in advanced renal disease)
Gout meds not used
in pregnancy except for probenecid
Gout Meds not used in childern except
children except for uricemia of malignancy
Uric acid crystals when
crystals when mobilized can precipitate renal stones
Gastrointestinal (GI) disturbances
Gastrointestinal (GI) disturbances abound, and peptic ulcers can occur
Probenecid is
Probenecid is sulfa based
Allopurinol causes
causes hypersensitivity rash (higher in blacks and Hispanics)
Colchicine results in
Colchicine results in myopathy, weakness, neuropathy and malabsorption of B12
Uric acid more toxic
Uric acid more toxic in older adults
Probenecid is drug of choice
Allopurinal can be used for renal impairment
More likely toxic when combined with thiazides
Off-label use of chochicine in
pericarditis and sclerodema (seek consultation)
Bone loss occurs when there is imbalance
between osteoblast and osteoclast activities.
Osteoporosis is diagnosed when bone density is
2.5 standard deviations below average.
Bone is histologically and biochemically
normal
Osteoporosis risk for
fractures, especially at areas of stress, increases.
Osteoporosis Risk Factors
Family history, Age greater than 70 years Slight build Fair complexion Low calcium and/or vitamin D diet Minimal sun exposure Weight less than 70 kg Sedentary lifestyle
osteoprosis risk factors continueed
Glucocorticoid use greater than 5 mg/day for longer than 3 months
Anticonvulsants (phenobarbitol, phenytoin, carbamazepine)
Long-term proton pump inhibitor
Heavy tobacco or alcohol use
Aromatase inhibitors
Young African American women have higher bone density, but risk increases with age.
Traditionally have lower calcium intake
Asian women are at high risk.
Traditionally consume inadequate calcium
Hispanic women have similar risk as white women
Pharmacodynamics - Estrogen prevents
bone resorption action of PTH.
bone resorption action of PTH.
Have estrogenic effects on bone
Raloxifene (Evista)
Bisphosphonates reduce bone
resorption by inhibiting osteoclast activity.
Calcium and vitamin D together
not individually) prevent and treat osteoporosis.
Osteoperosis what is the best treatment
Prevention is the best treatment.
Adequate calcium intake with vitamin D
Low-impact bone-strengthening exercise (not swimming)
osteoprosis no evidence of
optimal time of duration
Some molecules have 10-year half-life!
Starting medications in osteopenia status no longer considered good practice for most patients
This may vary with oncology patients on aromatase inhibitors
Estrogen - low
Low-dose therapy maintains bone mineral density (BMD)
calcium combination of
Combination of diet and calcium supplement to meet daily requirement
Vitamin D required to enhance absorption
bisphonates no
longer used for preventative therapy!
First-line therapy for postmenopausal women with osteoporosis
First-line therapy for men older than age 70 years with osteoporosis
Selective estrogen receptor modulators (SERMs):
Reloxifene (Evista) is prototype, newer agents available
Also protective against breast cancer
Teriparatide (human PTH)
Reserved for highest-risk patients who cannot take bisphosphonates or do not respond to them
Questionable cancer risk
Denosumab: expensive
All the risks of other biologicals
Before treatment, rule out other disorders that may cause further low bone density. such as
Hyperparathyroidsim
Vitamin D deficiency
Hyperthyroidism
Renal disease
Measure BMD
loss and gold standard
Measure BMD
DEXA Screening sholuld be used for
Women who are long-term estrogen deficient
Women and men with vertebral abnormalities
Monitoring treatment of osteoporosis
No firm guideline for how often to do so
Patients on long-term glucocorticoid or thyroid therapy
Patients with diseases that have the risk of osteoporosis development
Women older than age 40 years who have a fracture
dexa screening all women older than
65 for baseline evaluation
Additional considerations
for Dexa
Body weight less than 127 lb or body mass index (BMI) of 20 or less
Current smoker
Surgical menopause at age less than 40 years
Amenorrhea for more than a year in premenopausal female
Immobility for over 1 year
Osteopenia begins
Osteopenia 2 to 5 years after menopause if no HRT/estrogen therapy
No evidence for how fast or IF patient will progress to osteoporosis
Consider referral for
complex cases or those who do not respond to therapy
