Gout Meds

Question 1

gout is a disorder of metabolism of what? what is depositing and where?

Answer 1

purine metabolism

uric acid crystallizes in form of monosodium urate and precipitates in joints, on tendons and in surround tissues

Question 2

enzyme responsible for breaking down uric acid?

Answer 2

uricase

Question 3

pathognomonic sign of gout?

Answer 3

tophi

Question 4

causes of hyperuricemia? main cause?

Answer 4

diet
genetic predisposition
under-excretion of urate
main cause is renal under-excretion of uric acid

Question 5

how to definitively diagnose gout?

Answer 5

identification of monosodium urate crystals in synovial fluid or a tophus

Question 6

what needs to be done on all synovial fluid aspirations?

Answer 6

culture!

Question 7

appearance of monosodium urate crystals under polarized light microscopy?

Answer 7

needle-like morphology and strong (=) birefringence pattern

Question 8

most important condition to differentiate possible gout from?

Answer 8

septic arthritis

gout can also look like pseudogout and rheumatoid arthritis

Question 9

radiography appearance of gout?

Answer 9

“rat-bite” erosions

Question 10

overconsumption of what EtOH increases risk for gout?

Answer 10

beer - b/c it is high in purines

Question 11

cause of pseudogout? where do you see it?

Answer 11

calcium pyrophosphate crystals in the joints

see ssxs in knee, wrist or ankle

Question 12

what pharmaceutical agent increases the risk of gout attacks? what drug within it’s category does not increase the risk? what two other drugs increase the risk of gout?

Answer 12

diuretics have been assoc w/gout attacks
hydrochlorothiazide however does not seem to increase the risk
niacin and aspirin increase the risk

Question 13

triggers of gout?

Answer 13

low temperatures
trauma
surgery
chemo
diuretics
stopping or starting allopurinol

Question 14

what two HTN drugs have a decreased risk of gout?

Answer 14

CCBs and losartan

Question 15

MC spot for a gout attack?

Answer 15

big toe joint
can also appear in heels, knees, wrists and fingers
usu pn begins over 204 hrs and during the night

Question 16

first line tx of gout? CCIs to gout?

Answer 16

NSAIDs (indomethacin) are usu first line tx

not recommended in those w/certain health problems such as GI bleed, renal failure, heart failure

Question 17

what 2 drugs can be used to protect the stomach from NSAID use? which one will speed up damage to the stomach w/NSAID use?

Answer 17

protective: PPIs and misoprostol

speed up damage: H2 blockers

Question 18

3 txs for an acute gouty attack?

Answer 18

NSAIDs
steroids
colchicine

Question 19

3 prophylactic tx options?

Answer 19

colchicine
allopurinol
probenecid

Question 20

category of indomethacin/indocin? indications? MOA? how to deliver?

Answer 20

category: NSAID
indications: gout, arthritis, bursitis, migraines, hemicrania, pain and swelling
MOA: COX I and COX 2 inhibitor
generally given PO

Question 21

sampter’s triad?

Answer 21

allergy to aspirin or other NSAIDs
nasal polyps
asthma

Question 22

C/Is of indomethacin/indocin? use in caution with what pts?

Answer 22

C/Is: allergy to, nasal polyps, children less than 2 yo, severe pre-existing renal and liver damage
caution: hx of ulcers, bleeding tendencies, Parkinson’s, epilepsy, psychotic d/os, concurrent use of potassium sparing diuretics, significant HTN

Question 23

SEs of indometacin/indocin?

Answer 23

SEs: bleeding, gastritis, PUD, may exacerbate HTN or CHF

Question 24

category of cortisone? indications? MOA?

Answer 24

category: steroid
indications: short-term pn relief and reduced swelling from inflammation of a jt, tendon or bursa as well as for marked allergic rxn or post-EPI tx of anaphylaxis
MOA: decreases inflammation by inhibiting pro-inflammatory proteins

Question 25

MOA of glucocorticoids?

Answer 25

bind to glucocorticoid receptor, actives it which in turn up-regulates the expression of anti-inflammatory proteins in the nucleus and represses pro-inflam proteins by preventing the translocation of other transcription facts from the cytosol into the nucleus

Question 26

delivery method of cortisone? SEs?

Answer 26

can give intra-articular injection, PO, IM, IV, spray and apply topically
SEs: hyperglycemia, insulin resistance, DM, osteoporosis, anxiety, depression, amenorrhea, cataracts, glaucoma

Question 27

primary anti-inflam mech of glucocorticoids?

Answer 27

lipocortin-1

Question 28

action of lipocortin-1?

Answer 28

both suppresses phospholipase A2 (blocks eicosanoid production) and inhibits various leukocyte inflammatory events

Question 29

potential SEs of IM or IA cortisone injections?

Answer 29

pain, infxn, skin pigment changes, loss of fatty tissue and tendon rupture

Question 30

when utilizing cortisone topically what are the 5 medications typically used?

Answer 30

beclometasone, budesonide, fluticasone, mometasone, ciclesonide

Question 31

category of colchicine? indications? MOA?

Answer 31

category: mitotic inhibitor
indications: gout (flares and prophylaxis)
MOA: inhibits microtubule polymerization by binding tubulin; availability of tubulin is essential to mitosis therefore inhibited; also inhibits neutrophil motility and neutrophil activity so anti-inflammatory as well

Question 32

therapeutic index of colchicine?

Answer 32

relatively low

Question 33

how to give colchicine? SEs? overdose sxs?

Answer 33

given PO
SEs: GI upset, anemia, neutropenia, hair loss, peripheral neuropathy, neutropenia, thrombocytopenia
overdose sxs: vomiting, diarrhea, acute renal failure and possible hypovolemic shock, no specific antidotes are known

Question 34

ssxs of colchicine poisoning

Answer 34

burning in mouth, throat, fever, vomiting, diarrhea, abd pn, KD failure, hypovolemic shock dt extreme vascular damage and fluid loss through the GI tract, KD damage resulting in low urine output, bloody urine, low WBC count, anemia, muscular weakness, respiratory failure

Question 35

category of allopurinol? indications? MOA? how to deliver? SEs?

Answer 35

category: purine analog
indications: hyperuricemia, gout, prophylaxis against tumor lysis syndrome
MOA: xanthine oxidase inhibitor
deliver PO
SEs: N/V, skin rash, Stevens-Johnson Syndrome, toxic epidermal necrolysis, hypersensitivity syndrome: fever, skin rash, eosinophilia, hepatitis, decreased renal fxn

Question 36

allopurinol is a structural isomer of what? what does it inhibit and why is this important in treating gout?

Answer 36

structural isomer of hypoxanthine
inhibits enzyme xanthine oxidase which is responsible for successive oxidation of hypoxanthine and xanthine and ultimately uric acid production

Question 37

what are uricosuric meds?

Answer 37

substances that increase the excretion of uric acid in the urine thus reducing the concentration of uric acid in blood plasma
by decreasing plasma uric acid levels, uricourics help to dissolve these crystals while limiting the formation of new ones

Question 38

SE of uricosuric meds?

Answer 38

can lead to KD stones

so C/I in those who already have a high urine concentration of uric acid

Question 39

category of probenecid/probalan? indications? MOA? how to give? SEs?

Answer 39

category: uricosuric
indications: hyperuricemia, gout
MOA: probenecid works by interfering w/the KDs organic anion transporter, which reclaims uric acid from the urine and returns it to the plasma thus reabsorption of uric acid is decreased
give PO
SEs: N/V, skin rash, SJS, hypersensitivity syndrome: fever, skin rash, eosinophilia, hepatitis, decreased renal fxn, gastritis, possible drug induced hepatitis, dizziness, may cause KD stones

Question 40

off-label use of probenecid?

Answer 40

extends the duration of action of penicillin

Question 41

if pt experiences exacerbation of gout following probenecid/probalan therapy what to prescribe next?

Answer 41

can prescribe colchicine