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III. Clinical Pharmacy > Gout and Hyperuricemia > Flashcards

Gout and Hyperuricemia Flashcards

1
Q

Gout involves:

A
  • hyperuricemia
  • recurrent attack of acute arthritis with MSU crystals
  • interstitial renal disease
  • uric acid nephrolithiasis
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2
Q

End product of purine degradation

A

Uric acid

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3
Q

Purines originate form: CLUE: 3 processes

A
  • dietary purine
  • conversion of tissue nucleic acid to purine
    nucleotides
  • de novo synthesis of purine bases
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4
Q

abnormalities in enzyme systems that

regulate purine metabolism may cause what type of uric acid production? Over or under

A
  • Overproduction of uric acid
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5
Q

Overproduction of uric acid involves what enzymes?

CLUE: 2 enzymes

A
  • PRPP

- HGPRT

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6
Q

What is PRPP?

A

-Phosphoribosyl pyrophosphate synthetase

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7
Q

What is HGPRT?

A

-Hypoxanthine-guanine phosphoribosyl transferase

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8
Q

Amount or level of PRPP in uric acid production (overproduction)?

A
  • increase
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9
Q

Amount or level of HGPRT in uric acid production (overproduction)?

A

-decrease

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10
Q

Decline in urinary excretion to a level below rate of production leads to:

A
  • Hyperuricemia

- Increase of sodium urate

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11
Q

Drugs that decrease renal uric acid clearance include:

A
  • diuretics
  • nicotinic acid
  • salicylates (<2 g/day)
  • ethanol
  • pyrazinamide
  • levodopa
  • ethambutol
  • cyclosporine
  • cytotoxic drugs
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12
Q

Other term for urate deposits?

A

Tophi

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13
Q

Clinical presentation of acute gout attacks:

A
  • rapid onset of excruciating pain
  • swelling
  • inflammation
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14
Q

Untreated attacks last from?

A

3 to 14 days

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15
Q

Diagnosis of gout:

A
  • aspiration of synovial fluid

- identification of intracellular crystals of MSU monohydrate in synovial fluid

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16
Q

Nonpharmacologic therapy for gout?

A
  • local ice application
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17
Q

Is dietary supplements recommended for the treatment of gout?

A
  • No
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18
Q

Pharmacologic therapy for gout includes:

A
  • NSAIDs
  • Corticosteroids
  • Colchicine
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19
Q

Three nonsteroidal inflammatory drugs that have FDA approval for gout?
CLUE: INS

A
  • Indomethacin
  • Naproxen
  • Sulindac
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20
Q

NSAIDs common adverse effects in GI tract: (3)

A
  • Gastritis
  • Bleeding
  • Perforation
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21
Q

NSAIDs common adverse effects in Kidneys: (2)

A
  • renal papillary necrosis

- reduced creatinine clearance

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22
Q

NSAIDs common adverse effects in Cardiovascular system: (3)

A
  • increased blood pressure
  • sodium retention
  • fluid retention
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23
Q

NSAIDs common adverse effects in CNS: (3)

A
  • impaired cognitive function
  • HA
  • dizziness
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24
Q

True or False:
Systemic therapy is necessary if an attack is
polyarticular.

A
  • True
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25
Q

Interleukin-1 Inhibitor Therapy can be given if there is an inadequate response to combination therapy?

A
  • True
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26
Q

Initial dose for Etodolac (Usual range: 300-500 mg twice daily)

A

300 mg twice daily

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27
Q

Initial dose for Fenoprofen (Usual range: 400–600 mg three to four times
daily)

A
  • 400 mg three times daily
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28
Q

Initial dose for Ibuprofen (Usual range: 400–800 mg three to four times
daily)

A
  • 400 mg three times daily
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29
Q

Initial dose for Indomethacin (Usual range:50 mg three times daily initially
until pain is tolerable then rapidly
reduce to complete cessation)

A
  • 50 mg three times daily
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30
Q

Initial dose for Ketoprofen (Usual range: 50–75 mg three to four times daily)

A
  • 75 mg three times daily or 50 mg

four times daily

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31
Q

Initial dose for Naproxen

A
  • 750 mg followed by 250 mg every

8 h until the attack has subsided

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32
Q

Initial dose for Piroxicam

A
  • 20 mg once daily or 10 mg twice

daily

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33
Q

Initial dose for Sulindac (Usual range: 150–200 mg twice daily for 7–10
days)

A
  • 150 mg twice daily
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34
Q

Initial dose for Celecoxib

A
  • 800 mg followed by 400 mg on
    day 1, then 400 mg twice daily
    for 1 week
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35
Q

Prednisone or prednisolone oral dosing strategies: (1)

A
  • 0.5 mg/kg daily for 5 to 10

days followed by abrupt discontinuation

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36
Q

Prednisone or prednisolone oral dosing strategies: (2)

A
  • 0.5 mg/kg daily for 2 to 5

days followed by tapering for 7 to 10 days

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37
Q

Methylprednisolone dose pack dosing strategy?

A
  • a 6-day regimen starting with 24 mg on day 1 and

decreasing by 4 mg each day

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38
Q

Dose of Methylprednisolone in a dose pack strategy at day 4?

A

-12 mg

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39
Q

An intra-articular corticosteroid given at 20-40 mg if the gout is limited to one r two joint

A
  • Triamcinolone acetonide
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40
Q

T/F:
IA corticosteroids should generally be used with oral
NSAID, colchicine, or corticosteroid therapy.

A
  • True
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41
Q

A long acting corticosteroid used for gout given by a single IM injection followed by oral corticosteroid therapy

A

Methylprednisolone

42
Q

Caution use of corticosteroid in patients with?

A
  • Diabetes
  • GI problems
  • Bleeding disorders
  • Cardiovascular disease
  • Psychiatric disorders
43
Q

T/F:
Long-term use of Corticosteroid increase risk for osteoporosis, hypothalamic–
pituitary–adrenal axis suppression, cataracts, and muscle deconditioning.

A
  • True
44
Q

ACTH means?

A

Adrenocorticotropic hormone

45
Q

How many units of ACTH gel can be given IM every 6-8 hrs for 2-3 days and then discontinued?

A
  • 40 to 80 USP units
46
Q

T/F:
ACTH gel has Limit use for patients with
contraindications to first-line therapies (eg, heart failure, chronic renal failure, history of GI bleeding) or patients unable to take oral medications.

A
  • True
47
Q

Drug that is highly effective in relieving acute gout attacks?

A
  • Colchicine
48
Q

It can only be use within 36 hours of attack onset

A
  • Colchicine
49
Q

T/F:

Colchicine causes dose-dependent GI adverse effects (nausea, vomiting, and diarrhea).

A
  • True`
50
Q

Non-GI effect of Colchicine?

A
  • Neutropenia

- Axonal neuromyopathy

51
Q

Colchicine is CI with (enzyme) since it reduced biliary excretion which leads to increased plasma colchicine levels and toxicity

A
  • P-glycoprotein or strong CYP450 3A4 inhibitor
52
Q

An example of CYP450 3A4 inhibitor?

A
  • Clarithromycin
53
Q

An FDA approved colchicine product available in 0.6 mg oral tablets?

A
  • Colcrys
54
Q

Recommended dose of Colcrys?

A
  • 1.2 mg (two tablets) initially, followed by 0.6 mg (one tablet)
    1 hour later
55
Q

T/F:
Although not an FDA-approved regimen, the American College of
Rheumatology (ACR) gout treatment guidelines suggest that colchicine 0.6 mg once
or twice daily can be started 12 hours after the initial 1.2 mg dose and continued until
the attack resolves.

A
  • True
56
Q

T/F:

Recurrent gout attacks can be prevented by maintaining low uric acid levels

A
  • True
57
Q

T/F:
Gout is not necessarily a contraindication to use of thiazide diuretics in
hypertensive patients.

A
  • True
58
Q

T/F:
High-dose aspirin for cardiovascular prevention should be
continued in patients with gout because aspirin has a negligible effect on elevating
serum uric acid

A
  • False (Low-dose)
59
Q

T/F:
Urate-lowering therapy can be started during an acute attack if anti-inflammatory
prophylaxis has not been initiated.

A
  • False
60
Q

T/F:
The goal of urate-lowering therapy is to achieve and maintain serum uric acid less
than 6 mg/dL (357 µmol/L), and preferably less than 5 mg/dL (297 µmol/L) if signs
and symptoms of gout persist.

A
  • True
61
Q

T/F:

Urate lowering should not be prescribed for long-term use

A
  • False
62
Q

MOA of Xanthine oxidase inhibitors?

A
  • Decrease synthesis of uric acid
63
Q

MOA of Uricosurics?

A
  • Increase renal excretion of uric acid
64
Q

Recommended first-line therapy for hyperuricemia?

A
  • Xanthine oxidase inhibitors
65
Q

Examples of uricosuric agent?

A
  • Probenecid
  • Losartan
  • Fenofibrate
66
Q

Alternative therapy in PXs with a CI or intolerance to Xanthine oxidase inhibitors?

A
  • Uricosuric agent (Probenecid)
67
Q

T/F:
In refractory cases, combination therapy with a xanthine
oxidase inhibitor plus a drug with uricosuric properties (probenecid, losartan, or
fenofibrate) is suggested.

A
  • True
68
Q

T/F:
Pegloticase may be used in severe cases in which the patient
cannot tolerate or is not responding to other therapies

A
  • True
69
Q

T/F:

Diuretics, Niacin, Calcineurin inhibitors can elevate Urate levels?

A
  • True
70
Q

Examples of XOI?

A
  • Allopurinol

- Febuxostat

71
Q

ULT initiation first-line treatment is XOI while the Alternative is Probenecid?

A
  • True
72
Q

Serum urate level needed to be maintained ?

A
  • less than 6mg/dL
73
Q

T/F:

If the Urate target is not achieved after ULT initiation then titration of ULT to minimum dose is required?

A
  • False (maximum dose)
74
Q

T/F:

Switching to pegloticase when urate target is achieved using XOI plus uricosuric therapy?

A
  • False (not achieved the switch to pegloticase)
75
Q

First line for Anti-inflammatory Gout Prophylaxis during ULT initiation are:

A
  • low-dose colchicine

- low-dose NSAID

76
Q

T/F:
Low-dose prednisone or prednisolone is the second line treatment for Anti-inflammatory Gout prophylaxis during ULT initiation?

A
  • True
77
Q

T/F:
Xanthine oxidase inhibitors reduce uric acid by impairing conversion of hypoxanthine to xanthine and xanthine to uric acid.

A
  • True
78
Q

Recommended starting dose for Allopurinol?

A
  • Not greater than 100 mg daily
79
Q

Recommended starting dose for Allopurinol in patients with Chronic kidney disease?

A
  • Not greater than 50 mg/ day
80
Q

Mild adverse effect of Allopurinol:

A
  • Skin rash
  • Leukopenia
  • GI problems
  • HA
  • Urticaria
81
Q

More severe adverse effect of Allopurinol:

A
  • severe rash

- Allopurinol hypersensitivity syndrome

82
Q

Allopurinol hypersensitivity syndrome characterized by:

A
  • Fever
  • Eosinophilia
  • Dermatitis
  • Vasculitis
  • Renal and Hepatic dysfunction
83
Q

Brand name of Febuxostat?

A
  • Uloric
84
Q

What is the recommended starting dose for Febuxostat?

A
  • 40 mg OD
85
Q

T/F:
Increase the dose to 80 mg once daily
for patients who do not achieve target serum uric acid concentrations after 2 weeks of
therapy

A
  • True
86
Q

Adverse events of Febuxostat:

A
  • Nausea
  • Arthralgias
  • Minor hepatic transaminase elevations
87
Q

T/F:
Probenecid increases renal clearance of uric acid by inhibiting the post-secretory
renal proximal tubular reabsorption of uric acid.

A
  • True
88
Q

Is uricosurics can be given to patients that have history of urolitihasis?

A
  • No
89
Q

T/F:
Start therapy with uricosurics at a low dose to
avoid marked uricosuria and possible stone formation.

A
  • True
90
Q

T/F:
Initial probenecid dose is 250 mg twice daily for 1 to 2 weeks, then 500 mg twice daily
for 2 weeks

A
  • True
91
Q

T/F:
Increase the daily dose thereafter by 500-mg increments every 1 to 2 weeks
until satisfactory control is achieved or a maximum dose of 2 g/day is reached.

A
  • True
92
Q

Major side effects of Probenecid:

A
  • GI irritation
  • Rash
  • Hypersensitivity
  • Precipitation of acute gouty arthritis
  • Stone formation
93
Q

T/F:
impaired renal function (CLcr <50 mL/min or <0.84 mL/s) and overproduction of
uric acid are the contraindications for Allopurinol?

A
  • False ( for Probenecid)
94
Q

Brand name of Pegloticase?

A
  • Krystexxa
95
Q

T/F:

Pegloticase is a pegylated recombinant uricase?

A
  • True
96
Q

MOA of Pegloticase?

A

Reduces serum uric acid by converting uric acid to allantoin

97
Q

A drug that is indicated for antihyperuricemic therapy in adults refractory to conventional therapy?

A
  • Pegloticase
98
Q

T/F:

The dose for Pegloticase is 8 mg by IV infusion over at least 2 hours every 2 weeks

A
  • True
99
Q

T/F:
For patients on long-term
NSAID prophylaxis, a proton pump inhibitor or other acid-suppressing therapy is
indicated to protect from NSAID-induced gastric problems

A
  • True
100
Q

Dose of prednisolone as an alternative for Px with intolerance, CI or lack of response to 1st line therapy for Anti-inflammatory prophylaxis during initiation of ULT?

A
  • less than 10 mg /day

III. Clinical Pharmacy (3 decks)

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