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Clinical Pharmacology Exam 3 > Gout > Flashcards

Gout Flashcards

1
Q

Should we treat patients with asymptomatic hyperuricemia?

A

-Uh uh uh uh uh No

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2
Q

When you find gout, what should you screen for?

A
  • HTN, DM, CKD, & hyperlipidemia

- Gout = metabolic syndrome

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3
Q

What are the goals of gout therapy??

A
  • Treat acute disease: NSAIDs, colchicine, steroids
  • Preventing flares/recurrences: Prophylaxis of Colchicine or NSAIDs during initiation of urate-lowering agent (allopurinol, probenecid)
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4
Q

What NSAIDs are recommended for acute gout?

A
  • Use ibuprofen or naproxen

- Take until acute gouty attack is completely resolved

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5
Q

Oral prednisone is indicated for patients with what comorbidities due to its safety profile?

A

-Oral prednisone for patients with kidney disease, cirrhosis, and heart failure

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6
Q

What drug is “last resort” for acute gout management given cost and drug interactions

A

-Colchicine

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7
Q

What three drugs are all 1st line for acute gout management? How do we choose between them?

A
  • Colchicine, steroids, NSAIDs
  • Choice should be based on patient preference, prior response, & other comorbidities
  • Avoid systemic corticosteroids + NSAIDs due to synergistic GI toxicity
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8
Q

Colchicine Indications

A
  • used for ACUTE gout flares*
  • Added to ASA in the context of pericarditis
  • Familial Mediterranean Fever

It is pricey $$$

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9
Q

Colchicine CYP interactions

A
  • Major substrate of 3A4 & PgP

- Fatal toxicity reported in patients with a strong inhibitor of CYP3A4 (clarithromycin) or P-gp (cyclosporine)

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10
Q

When you mix colchicine with a statin or a fibrate, what is possible?

A

-Myopathy and rhabdomyolysis

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11
Q

What is the ADR associated with almost everyone in the old dosing regimen?

A

-Poopy pants diarrhea

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12
Q

What is involved in the comprehensive gout assessment with the goal of prevention of acute attacks?

A
  • BP, BMI assessment
  • ETOH use
  • Smoking
  • CV risk
  • BUN/Cr, eGFR
  • Glucose
  • Lipids
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13
Q

What are some non-pharm recommendations/dietary changes for gout patients?

A
  • Weight loss
  • Exercise
  • Avoid sugar sweetened beverages & foods with added sugars
  • Avoid High purine meats
  • Avoid alcohol (beer»spirits)
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14
Q

What were the three bolded populations that get anti-hyperuricemic therapy?

A
  • Frequent/disabling gouty attacks
  • Gout with CKD
  • Men <25 years old or premenopausal women
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15
Q

You initiate anti-inflammatory prophylaxis when starting or just prior to starting UA lowering meds. What meds do we use? How long do we take them?

A
  • 1st line: colchicine, NSAIDs
  • 2nd line: Low dose prednisone

-minimum of 6 month duration

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16
Q

Xanthine Oxidase Inhibitors

A
  • Allopurinol > febuxostat

- first line options

17
Q

Uricosuric Agents

A
  • Probenecid: essentially a uric acid diuretic

- Fenofibrate and losartan also used and can be added to a xanthine oxidase inhibitor

18
Q

-What is the “treat to target” theory in gout. What is a pearl about how fast we lower uric acid

A
  • Goal is to get serum urate <6 or <5 if tophi are present

- Lowering slowly associated with lowest rate of recurrent acute attacks

19
Q

When do you usually start anti-hyperuricemic therapy? (think about timing with the flares)

A
  • Generally start 2-4 wks after flare resolution

- Duration of therapy indefinite to remain effective

20
Q

Allopurinol MOA

A

-Inhibition of conversion of hypoxanthine to xanthine to uric acid

21
Q

Allopurinol indications

A
  • Prevention of hyperuricemia associated with gout & urate nephrolithiasis
  • Also used to prevent acute uric acid nephropathy during chemotherapy for malignancies (tumor lysis syndrome*)
22
Q

Prior to initiation of allopurinol, what gene do we need to screen for and why?

A
  • HLA-B*5801 (Just know HLA testing)

- at higher risk for hypersensitivity rxns

23
Q

Should we stop xanthine oxidase inhibitors during acute attacks?

A

-Uh uh uh uh uh No

24
Q

What is a pearl about the dosing of Allopurinol?

A
  • Adjust for GFR due to accumulation of alopurinol and metabolites
  • Low and slow! Doses gradually increased 2-4wks based on serum UA
25
Q

Allopurinol Monitoring

A
  • CBC
  • LFTs periodically
  • Serum Uric acid
26
Q

You should avoid allopurinol in patients taking these three drugs

A
  • 6-metacaptopurine
  • Azathioprine
  • Theophylline
27
Q

Allopurinol ADRs

A
  • Paradoxical gout flare: encourages crystal shedding through partial crystal dissolution**
  • Bone marrow suppression
  • Drug rash/fever
28
Q

Allopurinol “Special ADR’s”

A

-DRESS syndrome: fever, rash, hepatitis, eosinophilia, AKI

29
Q

Febuxostat MOA

A
  • Xanthine oxidase inhibitor

- Not a purine base analogue (unlike allopurinol)

30
Q

Febuxostat indications

A
  • Same as allopurinol

- Use in patients intolerant to allopurinol

31
Q

Febuxostat ADRs

A
  • Paradoxical gout flare

- LFT abnormalities

32
Q

Probenecid MOA

A

-Promotes UA clearance by inhibiting the urate-anion exchanger at the proximal tubule which modulates reabsorption of urate

“urate diuretic”

33
Q

Probenecid Indications

A
  • Prevention of hyperuricemia secondary to impaired renal excretion of UA ass with gout
  • Pts must have adequate renal fcn (CrCl >50 mL/min)
34
Q

Probenecid Contraindications

A

-Don’t use in patients with prior nephrolithiasis

35
Q

Probenecid ADRs

A
  • May precipitate acute gout*
  • Uric acid stone formulation*
  • Rash
  • N/V/D
36
Q

Pegloticase MOA

A
  • Reduces serum UA by catalyzing oxidation of UA, which makes it easier to excrete (allantoin)
  • Used to treat chronic severe symptomatic gout in adults who have not responded to maximum doses of xanthine oxidase inhibitor
37
Q

Pegloticase CI/ADR

A

-CI in G6PD deficiency

ADR

  • Paradoxical gout flare, maybe severe
  • Infusion rxns
  • Anaphylaxis
38
Q

What two drugs are used for off-label gout tx?

A
  • Losartan

- Fenofibrate

Clinical Pharmacology Exam 3 (19 decks)

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