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Muscoskeletal > Gout and hyperuricemia day 2 > Flashcards

Gout and hyperuricemia day 2 Flashcards

1
Q

What agent is first line in acute gout attack?

A

NSAID

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2
Q

What is the most common NSAID used for treatment of gout?

A

Indomehacin 50 mg TID but any are good

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3
Q

What is the treatment course of NSAIDS?

A

start within 24 hours of onset
use maximal doses
continue until complete resolution then tamper over 2-3 days

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4
Q

What are the adverse effects of NSAIDs?

A

GI
renal impairment
increased BP

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5
Q

When do you use caution with NSAIDs?

A 
peptic ulcer disease
HF
uncontrolled HTN
renal impairment
CAD
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6
Q

Based on ACR when is it recommended to give colchicine?

A

within 36 hours

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7
Q

What is the MOA of Colchicine?

A

interferes with inflammation
inhibits phagocytosis
blocks release of chemotactic factors

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8
Q

What is the dose of colchicine?

A

1.2 mg initially then .6 mg an hour later
off label is 1.2 mg initially then .6 12 hours later and continute 1-2x/day until resolved
NO renal adjustments

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9
Q

What are the adverse reactions for colchicine?

A

N/V/D
neutropenia
neuromyopathy

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10
Q

What are the drug interactions of Colchicine?

A

dose adjustments with PGP and CYP 3A4 drugs (azoles, macrolides especially clarithromycin)

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11
Q

When is Colchicine contraindicated?

A

renal or hepatic impairment with PGP or strong CYP 3A4 inhibitor

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12
Q

When do you use corticosteroids?

A

when no response with NSAIDs or Colchicine

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13
Q

What is the oral dosing of corticosteroids?

A

prednisone .5 mg/kg QD for 5-10 days
prednisone .5 mg/kg daily for 2-5 days then tampered down
methylprednisolone dose pack (6 days)

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14
Q

What is the Intraarticular dose and when is it used for corticosteroids?

A

if only 1-2 joints.

Triamcinolone 20-40 mg

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15
Q

What is the dose of IM for corticosteroids?

A

methylprednisolone single dose and followed by oral

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16
Q

When do you use caution with corticosteroids?

A 
history of GI problems
bleeding disorder
CV disease
DM
Pyschiatric dosorder
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17
Q

What 2 classes off treat acute gout?

A

IL- 1 inhibitors and Corticotropin

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18
Q

What IL-1 inhibitors help with gout and their dose?

A

Anakinra 100 mg SQ x3

Canakinumab 150 mg SQ for 1 dose

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19
Q

What is the dose of Corticotropin and how does it work?

A

40- 80 IM every 6-8 hours for 2-3 days

stimulates the adrenal cortex to produce cortisol and corticosterone

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20
Q

What do you use to treat for chronic prophylactic treatment?

A

Urate lowering therapy

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21
Q

What methods can you used to decrease urate concentration?

A

decrease synthesis of uric acis (xanthine oxidase inhibitor)
increase renal excretion of uric acid (uricosurics)

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22
Q

When can you use ULTs?

A

NOT to treat flare

can be started and continued during flare

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23
Q

What agents and doses are used with ULTs?

A

Colchicine .6 mg BID and .3 mg if renal problems
low dose NSAID (naproxen 250 mg bid)
2nd line: low dose corticosteroid of <10mg/day

24
Q

how long do you need to use the anti-inflammatory with ULT?

A

at least 3 months but typically 6 and if have tophi, use for 6 months after target reached

25
Q

What is the 1st line agent to decrease uric acid?

A

xanthine oxidase inhibitors

26
Q

When can you use xanthine oxidase inhibitors?

A

overproducers and underexcreters

27
Q

what is the MOA of xanthine oxidase inhibitors?

A

inhibits the activity of xanthine oxidase, an enzyme involved in purine metabolism

28
Q

What is the dose of Allopurinol?

A

start 100mg QD and maintenance is 100-300 mg day with a max of 800mg/day
titrate ecery 2-5 wks until goal reached
renal impaired start at 50 mg

29
Q

What are the ADRs of Allopurinol?

A

mild- skin rash, leukopenia, GI problems, HA, urticaria

severe- tens, hepititis, interstitial nephritis, eosinophillia, hypersensitivity

30
Q

What can cause allopurinol hypersensitivity?

A

presence of renal insufficiency or on thiazide
higher starting doses
have HLA-B*5810 are at higher risk

31
Q

What is the dose of Febuxostat?

A

initial 40 mg then increase to 40-80 mg with NO renal adjustments

32
Q

What aer the ADRs with Febuxostat?

A

liver function abnormalities, nausea, joint pain

33
Q

What is the MOA of uricosuric drugs?

A

increases renal excreation of uric acid

inhibits post secretory renal proximal tubule reabsorption of uric acid

34
Q

When can you ONLY use uricosuric drugs?

A

underexcreters

35
Q

What do you need to maintain with uricosuric drugs?

A

adequate urine flow and alkalinization of urine

36
Q

What are the ADRS of uricosuric drugs?

A

uric acid stones
GI irritation
rash and hypersensitivity
precipitation of acute gout arthritis

37
Q

When do you not use uricosuric drugs?

A

impaired renal function (<50)
history of renal stones
overproducers

38
Q

What is the dosing of Probenecid?

A

initial 250 mg BID for 1-2 wks then 500 mg BID for 2 wks

maintenance is increase 500mg every 1-2 wks with a max dose of 2g

39
Q

What levels can Probenecid increase?

A

penicillin
cephalosporin
sulfonamides
indomethacin

40
Q

When do you not use Probenecid?

A

CrCl <50

history of renal stones

41
Q

What is the dosing of Sulfinpyrazone?

A

initial is 100 mg BID and increase by 100 mg each week til at target goal with a max of 800 mg/day
avoid if CrCl<50

42
Q

What are the uricosuric drugs?

A

Probenecid

Sulfinpyrazone

43
Q

Is Sulfinpyrazone typically recommended?

A

No, side effects more severe and can act as anti platelet

44
Q

What is the MOA of Pegloticase?

A

pegylated recombinant uricase enzyme

breaks down uric acid to allantoin

45
Q

When do you use Pegloticase?

A

severe refractory cases when other agents are not tolerated or effective (>2 flares in 18 months, >1 tophi, or joint damage due to gout)

46
Q

What are the draw backs of Pegloticase?

A

ROA
AE
Cost
duration of efficacy

47
Q

What is the dose of Pegloticase?

A

8mg IV over 2 hours every 2 wks

48
Q

When is Pegloticase contraindicated?

A

in G6PD deficiency

49
Q

What are the AE of Pegloticase?

A

infusion reactions/anaphylaxis, gout flare, nausea, constipation, chest pain, vomiting

50
Q

What is the MOA of Fenofibrate?

A

increase clearence of hypoxanthine of uric acid

51
Q

What is the MOA of Losartan?

A

inhibits renla tubular reabsorption of uric acid and icreases urinary excretion

52
Q

When do you use Fenofibrate and losartan?

A

combined with xanthine oxidase inhibitor in refractory period

53
Q

What is the 1st line prophylaxis treatment?

A

allopurinol and febuxostat

54
Q

When do you monitor serum urate levels?

A

every 2-5 weeks

55
Q

What is the treatment for Nephrolithiasis?

A

drink because need to maintain 2-3L or urine/day
Need alkaline urine by bicarb 60-80 mEq/day, K citrate 60-80 mEq/day, and acetazolamide 250 mg hs
avoid purine rich foods
nmt 90g/day in protein
reduce uric acid excretion
treat with xanthine oxidase inhibitor

Muscoskeletal (9 decks)

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