Gout/AKI

Question 1

what are some indications for gout

Answer 1

rapid onset
pain and swelling
erythema
(+) monosodium urate crystals
Labs: increased WBC and SUA
history of alcohol use and red meat

Question 2

what are some risk factors for gout

Answer 2

alcohol use
high protein diet
AKI
dehydration
obesity
meds such as chlorthalidone (direutics)

Question 3

What are nonpharmacologic options for gout

Answer 3

ice (avoid heat)
reduce modifiable risk factors
- hydrate, exercise, weight loss
- DC thiazide diuretics
- diet –> reduce alcohol, red meats –> increase dairy

Question 4

common gout causing foods

Answer 4

seafood
beer
red meat
turkey, goose
drinks w/ high fructose corn syrup

Question 5

good foods for gout prevention

Answer 5

complex carbs
veggies
dairy
citrus fruits
fluids (not beer, juice, or caffeine)

Question 6

Pharm options for gout

Answer 6

NSAIDs
colchicine
oral corticosteroids (prednisone)

all are equally effective per ACR recommendations

Question 7

NSAID pros and cons

Answer 7

Pros: drug of choice, safer than colchicine, inexpensive

cons: renal effects, gastropathy, not good in HF or CKD, high doses (3-4x daily)

Question 8

Clinical Pearls of NSAIDs

Answer 8

indomethacin traditionally the DOC (50 mg TID)
Naproxen 750 mg load then 250 mg q 8 hrs (usual go to bc has lower Gi tox and less issues
sulindac 200 mg PO BID

Question 9

colchicine pros and cons

Answer 9

pros: effective if given in first 24 hrs, good if NSAID contraindicated bc of GI, prevent or treat

cons: N/V/D SE, neutropenia, bone marrow suppression, myopathy, not in CrCl <30

Question 10

Corticosteroid pros and cons

Answer 10

pros: DOC in renally impaired, IM can be nice for mono-articular gouty attacks

cons: not for long term (HPA axis suppression), hyperglycemia, nervousness, agitation, insomnia, HTN, fluid retention

Question 11

Clinical Pearl of CS

Answer 11

acutely CS can raise WBC but it is not indicative of infection

Question 12

Prednisone dose

Answer 12

no taper: 0.5 mg/kg/day for 5-10 d (usually said to be better!)
taper: 0.5 mg/kg/day for 2-5 and tapered for 7-10 days

Question 13

what two drugs can have uricosuric properties

Answer 13

losartan
fenofibrate

Question 14

Preventative Tx for gout

Answer 14

allopurinol
probenecid
febuxostat (Uloric)
pegloticase (Krystexxa)

Question 15

Primary recommendations for when to use preventive therapies

Answer 15

recurrent attacks (>2 annually)
tophi present
joint destruction on xray
uric acid kidney stones

Question 16

Conditional recommendations for when to use preventive therapies
Gout

Answer 16

less frequent flares (>1 flare in life but <2/year)

first gout flare with these risk factors
-CKD stage >3, SUA >9, urolithiasis

Question 17

what is the preferred agent for preventive therapy of gout

Answer 17

allopurinol

Question 18

when starting uric acid lowering therapy, rapid SUA change can also lead to a gout flare so…

Answer 18

PPX w steroids, NSAIDs, or colchicine is given with it during the first 3-6 months of therapy

Question 19

causes of pre-renal AKI

Answer 19

dehydrated
sepsis
hemorrhage
decreased CO
other intravascular depletion

Question 20

lab differentiation between pre-renal and intrinsic AKI

Answer 20

BUN/SCr ratio
> 20:1 = pre-renal
< 20:1 = intrinsic

Question 21

what agents should be avoided in AKI

Answer 21

diuretics, NSAIDs, ACE/ARB (short term)

Question 22

moderate intensity statin is recommended for px with LDL of ___ and we expect it to be reduced by ___

Answer 22

70-189 mg/dL

at least 30%