Gout Drugs

Question 1

NSAIDS

Answer 1

• Indomethacin, ibuprofen, naproxen, ketoprofen
• NOT aspirin, salicylate and tolmetin
• Front line agents for treating acute gout attacks by inhibiting COX-mediated PG synthesis as well as phago of uric acid crystals
• Start tx ASAP after sx onset and take regularly until resolution of flare
• Celecoxib: selective COX-2 inhibitor that may be better tolerated by pt. w/ GI issues i.e. PUD

Question 2

Colchicine

Answer 2

• Inhibits tubulin polymerization into MT and also interferes with leukocyte (PMN) and phagocyte migration and phagocytosis
• Oral tx for acute gouty attacks, relieves sx w/in 12-24 hrs
  Adverse effects: - N/V, abd pain
  Acute toxicity: burning throat pain, bloody diarrhea, shock, hematuria, oliguria
• NSAIDS used more frequently for acute attacks b/c of side effects but useful in pt. w/ renal dysfunction of PUD who can’t take NSAIDS

Question 3

Corticosteroids

Answer 3

• Tx for acute gouty flares when pt. had contraindications to other therapies
• Predisone/Prednisolone: 5-10 day oral regimens
• Triamcinolone acetonide: intra-articular therapy

Question 4

Xanthine Oxidase Inhibitors

Answer 4

• Inhibit XO to reduce biosynthesis of xanthine and uric acid
  Allopurinol: purine analog that acts as a suicide inhibitor (irreversible)
  Febuxostat: non-purine irreversible inhibitor of XO

Indications: - Preferred agents for gout therapy between attacks

Adverse Effects: - Both allopurinol and febuxostat may cause acute gouty attacks early in treatment when urate crystals are being withdrawn from the tissues –> initiate therapy w/ colchicine or an NSAID until the steady state serum urate is normalized to

Question 5

Uricosuric Agents

Answer 5

• Probencid and sulfinpyrzone
• Organic acids that act at the anion transport sites of the PCT to increase secretion and decrease reabsorption of uric acid
• Indicated when an XO inhibitor fails to lower serum urate to target levels
• Should not be used for analgesia in gout pt. b/c at analgesic doses aspirin inhibits the secretory urate transporter
• Used to decrease the body pool of uric acid in patients w/ tophaceous gout or those w/ increasingly frequent gouty attacks
• Should not start tx until 2-3 weeks after acute attack
  Adverse effects: - Both cause GI irritation and rash (administer in divided doses w/ food to lessen GI irritation)
• Increased UA excretion predisposes to renal stone – maintain high urine volume and keep urine pH above 6.0

Question 6

Pegloticase

Answer 6

• A pegylated recombinant mammalian uricase that lowers serum urate levels by converting uric acid to allantoin
• Tx for chronic gout that is refractory to standard urate lowering therapies
• Single IV dose can maintain low urate levels for up to 21 days and allows dosing every 2 weeks but must have adequate renal function
  Adverse Effects: - IV infusion reactions
• Gout flares in first 3 mo. of treatment (start on NSAIDs or colchicine prior to initiation of therapy)
• Pre-treatment w/ anti-histamines to avoid IV infusion reactions