gout + antiinflammatories Flashcards
what do you screen for when someone has gout
HTN, DM, hyperlipidemia, CKD
M/C cause of hyperuricemia
decreased excretion of urate by kidneys
2 main categories of gout MANAGEMENT
xanthine oxidase inhibitors
uricosuric agents
ACUTE gout anti-inflammatories
- NSAIDS - naproxen > ibuprofen
- prednisone (if CKD, cirrhosis, HF)
- colchicine
what two acute anti-inflammatory combos should you avoid & WHY
steroids, NSAIDS
can –> GI toxicity
risk factor reduction for gout
weight loss, decrease CV risk factors, manage BP, exercise, hydration, smoking
decrease intake of SSB (fructose!!), organ meats, red meats, ETOH
what pts should be on anti-hyperuricemic therapy
- frequent/disabling gout attacks (>2/yr)
- men <25 OR premenopausal women
- gout w CKD
ADRs of colchicine
- diarrhea
- myopathy, rhabdo
- bone marrow suppression
do not combine colchicine with…
- 3A4 or pgp inhibitors (clarithromycin, cyclosporine)
- statins, fibrates
goals of serum [UA] in gout
<6 or <5 if tophi
when do you initiate anti-hyperuricemic therapy
when acute gout attack has resolved
xanthine oxidase inhibitors
allopurinol
febuxostat
xanthine oxidase of choice
allopurinol
what to screen for with allopurinol and why
HLA-B5801 –> at higher risk of DRESS
what do you adjust for with allopurinol tx
GFR
ADR of allopurinol
paradoxical gout flare
bone marrow suppression
drug fever
rash, DRESS
BBW for febuxostat
cardiac safety concerns
uricosuric agent
probenecid
probenecid MOA
basically, urate diuretic
before starting someone on probenecid, pts must have
good renal function - GFR >50
pegloticase MOA
turns UA into a water soluble metabolite that can be excreted
when would you use pegloticase
severe gout, debulking for tophi, last resort!
biosimilars must have the same __ compared to OG drug
- MOA
- dose
- strength
- route
how soon should you initiate non-biologic DMARD therapy
within 3 months of the diagnosis
when should you use a biologic DMARD
when pt doesn’t respond to non-biologic, have moderate disease, or intolerant to DMARD
triple therapy anti-inflammatory regimen
MTX + hydroxychloroquine + sulfasalazine
biologic therapy anti-inflammatory regimen
MTX + TNF-inhibitor
what to use to decrease inflammatory symptoms
low dose steroids, NSAIDS
immunizations for people with inflammatory conditions
influenza pneumonia (both) VZV HBV HPV
when should immunizations be given
1 month prior to initiating DMARD
non-biologic DMARDS
- MTX
- leflunomide
- sulfasalazine
- hydroxychloroquine
- JAK inhibitors (-citinibs)
MTX MOA
folate antimetabolite that inhibits DNA synthesis
indications for MTX
- tumors/CA
- RA
- psoriasis/psoriatic arthritis
monitoring for MTX
- CXR, PFT
- HBV/HCV test
- CBC, CMP
ADRs for MTX
- stomatitis
- GI intolerance
- pulmonary toxicity
- hepatotoxicity (LFT abnormalities)
- nephrotoxicity
- bone marrow suppression
drug interactions of MTX
- other anti-folate drugs (TMP-SMX)
- other drugs that affect kidneys (NSAID, transplant drugs, diuretics)
- PPIs increase MTX conc.
what should you supplement MTX with & why
folate to decrease ADRs
when should you take pts off MTX & why
sick pts in hospital –> risk of aplastic crisis
reversal agent for MTX
levocovorin
leflunomide indications
RA/psoriatic arthritis in pt who had MTX toxicity
leflunomide ADRs
- diarrhea
- reversible alopecia
- LFT abnormalities
hydroxychloroquine indications
- RA
- SLE
- anti-malaria
do not use hydroxychloroquine if…
hx of retinal/visual field abnormalities
pts with renal insufficiency
hydroxychloroquine ADRs
- ophthalmic issues
- QTC issues
- hemolysis in G6PD pts
sulfasalazine indications
- RA
- IBD
common sulfasalazine ADRs
- GI intolerance
* sulfa rash!
JAK inhibitors
tofacitinib
baricitinib
upadacitinib
JAK inhibitor indications
mod-severe RA
what are pts on JAK inhibitors at risk of
thromboembolic events
1ST line TNF-inhibitors
- infliximab
- adalimumab
- etanercept
2nd line TNF inhibitors
certolizumab
golimumab
TNF inhibitors indications
- mod-severe RA
- psoriatic arthritis
- severe plaque psoriasis
- IBD
- ankylosing spondylitis
- sJIA
what are TNF-inhibitors typically used with
MTX
screening for pts on TNF inhibitors
CA TB (IGRA, TST) CXR HIV HBV HCV
acute ADRs of TNF-inhibitors
injection site rxn
infusion rxn
URTI
GI intolerance
serious ADRs of TNF inhibitors
- lupus
- MS
- bone marrow suppression
- malignancies
- increased risk for serious infections
what type of infections are pts on TNF inhibitors at risk of
TB reactivation
invasive fungal infection
bacterial infection
all other drugs biologic DMARDS (besides TNF-inhibitors) are generally only used for…
RA pts who dont respond to TNF inhibitor
T cell costimulation/activation inhibitor
abatacept
cd20 mab
rituximab
IL-1 antagonist
anakinra
IL-6 antagonist
toclizumab
sarilumab
acute psoriatic arthritis tx
NSAIDS, intraarticular or low-dose systemic steroids
long-term psoriatic arthritis tx
mild: NSAIDS
mod-severe: MTX, leflunomide –> add TNF-inhibitors if no improvement in 12-16 weeks –> then other agents
apremilast
PDE4 inhibitor
psoriatic arthritis
secukinumab
il-17 antagonist
ixekizumab
il-17 antagonist
ustekinumab
il-12/23 antagonist
what other non-biologic & biologic DMARD can you use for psoriatic arthritis
abatacept
tofacitinib
systemic juvenile idiopathic arthritis characteristics
daily high fever
evanescent MP rash
inflammatory polyarthritis
tx for mild-moderate sJIA
- NSAID
- systemic glucocorticoid
- or both
pts with sJIA with FEW systemic features (fevers)
- DMARD (MTX + TNFinhibitor)
pts with sJIA with prominent systemic features (fevers)
- high does corticosteroids
- tocilizumab or anakinra
- canakinumab
