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Therapeutics 1 > Gout Pharmacotherapy > Flashcards

Gout Pharmacotherapy Flashcards

1
Q

When assessing a gout attack, what are the first two questions you should ask a patient in determining treatment?

A

(1) How severe is the pain? scale of 1-10
(2) How many joints are affected?

the answer to these will determine monotherapy or combo therapy

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2
Q

Three FDA approved NSAIDs for acute gout management are:

A

Indomethacin
Sulindac
Naproxen

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3
Q

How are NSAIDs dosed for an acute gout attack?

A

initiated at the highest recommended dose and continued until 24 hours after symptoms resolve

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4
Q

contraindications for NSAID use

A

(1) hypersensitivity
(2) decompensated HF
(3) active GI bleed or peptic ulcer
(4) severe or acute renal impairment

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5
Q

Use NSAIDs with caution when:

A

(1) CrCl <50mL/min
(2) in combination with anticoagulant
(3) history of HF
(4) history of GI bleed or peptic ulcer
(5) uncontrolled hypertension

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6
Q

dosing for Indomethacin

A

one 50mg tablet TID

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7
Q

dosing for naproxen

A

750mg loading dose followed by 250mg every 8 hours

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8
Q

dosing for Sulindac

A

200mg BID

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9
Q

Adverse effects associated with NSAID use involve which body systems?

A

renal, CV, CNS, GI

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10
Q

What additional pharmacotherapy should be considered in patients that require NSAID use but have a history of peptic ulcer, alcoholism, or concomitant anticoagulation therapy?

A

PPI

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11
Q

For maximum efficacy, colchicine therapy must be initiated within ___ hours of an acute flare up.

A

24

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12
Q

colchicine dosing (normal renal function)

A

1.2mg loading dose, followed by 0.6mg one hour later, then 0.6mg QD or BID for the remainder of the attack

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13
Q

colchicine dosing (CrCl <30mL/min)

A

treatment: no dose adjustment necessary, but cannot repeat tx within 14 days of end
prophylaxis: 0.3mg QD

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14
Q

colchicine dosing (dialysis)

A

treatment: 0.6mg as a single dose
prophylaxis: 0.3mg twice weekly

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15
Q

colchicine adverse effects

A

GI, musculoskeletal, bone marrow suppression (aplastic anemia, thrombocytopenia)

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16
Q

corticosteroid options for gout flare-up treatment

A

(1) prednisone or prednisolone
(2) methylprednisolone
(3) triamcinolone

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17
Q

When are oral and intraarticular corticosteroids indicated for gout flare-ups?

A

oral: all cases
intraarticular: cases involving 1-2 large joints

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18
Q

corticosteroid adverse effects

A

(1) hyperglycemia
(2) fluid retention/weight gain
(3) N/V/D
(4) incr. appetite –> weight gain
(5) CNS (HA, insomnia)

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19
Q

Corticosteroid use is usually reserved for which kind of gout flare-ups?

A

(1) NSAID/colchicine intolerance
(2) polyarticular involvement
(3) resistant cases

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20
Q

Use corticosteroids with caution in patients who:

A

(1) have diabetes
(2) CHF
(3) immunosuppression
(4) psychiatric disorder
(5) peptic ulcer or GI bleed

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21
Q

An inadequate response to treatment for an acute gout attack is defined as:

A

either <20% reduction of pain within 24 hours or more than 24 hours have passed with <50% reduction of pain

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22
Q

Name 3 combination therapies that would be acceptable for treatment of a gout attack (if combo therapy warranted).

A

(1) NSAIDs + colchicine
(2) oral CS + colchicine
(3) intraairticular CS + all other modalities

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23
Q

One of the goals of urate-lowering therapy is a serum urate concentration of ______.

A

6 mg/dL or less

24
Q

Serum urate is monitored every ______ weeks during initiation, then every ______ once serum urate reaches a level of ______.

A

2-5, 6 months, <6 mg/dL

25
Q

Which class of medications are first-line for irate-lowering therapy? second-line? third-line?

A

xanthine oxidase inhibitors (allopurinol, febuxostat)
uricosurics (Probenecid)
Uricase agents (Pegloticase)

26
Q

starting dose of allopurinol (Zyloprim)

A

100 mg PO QD

27
Q

starting dose of allopurinol (Zyloprim) for CKD stage IV

A

50 mg PO QD

28
Q

Titration of Zyloprim is done every _____ weeks, and has a max dose of ______ QD.

A

2-4, 800 mg

29
Q

Common adverse effects of allopurinol

A

skin rash, pruritus, leukopenia, thrombocytopenia, GI intolerance

30
Q

allopurinol drug interactions

A

warfarin, antacids, mercaptopurine, azathioprine

31
Q

febuxostat starting and max dose

A

40 mg PO QD up to 80 mg PO QD

32
Q

The largest limitation of Uloric use is:

A

price

33
Q

True or false: dose adjustments for mild to moderate renal and hepatic impairment are necessary during febuxostat therapy.

A

false (however, use caution if CrCl <30 mL/min

34
Q

febuxostat adverse effects

A

(1) rash
(2) nausea
(3) abnormal LFTs

take precaution for CV thromboembolitic events

35
Q

main monitoring parameter for Uloric

A

LFTs (baseline, 2 mos, 4 mos)

36
Q

Uloric contraindications

A

concomitant use of azathioprine, mercaptopurine, or theophylline

37
Q

MOA of uricosurics

A

inhibit the reabsorption of filtered uric acid

38
Q

Probenecid (Benemid) is indicated for patients who:

A

(1) have documented underexcretion of uric acid
(2) have not reached target urate levels with XOI monotherapy
(3) cannot tolerate allopurinol (though it can be used in combo)

39
Q

dosing of Benemid

A

250 mg PO BID for 7 days, then increase to 500 mg PO BID for 14 days

may titrate by 500 mg q2weeks

max dose: 2g PO QD

40
Q

Why is it important to start with low doses of probenecid?

A

to avoid uricosuria and renal stone formation

41
Q

Probenecid adverse effects

A

flushing, pruritus, GI upset, stone formation, aplastic anemia/leukopenia

42
Q

Give one example of a uricase agent and its MOA.

A

Pegloticase, converts uric acid into allantoin, which is water soluble

43
Q

Krystexxa is indicated for ________ ________ _____.

A

refractory chronic gout (It’s a last case agent for those refractory despite tx with XOI, uricosuric)

44
Q

Krystexxa dosing

A

8 mg IV every 2 weeks administered over 120 minutes

45
Q

Patients using pegloticase should be pretreated with what two things?

A

antihistamines and corticosteroids

46
Q

Adverse effect of pegloticase.

A

infusion reactions, anaphylaxis, nephrolithiasis, arthralgia, HF exacerbations, nausea

47
Q

Precautions for Krystexxa therapy

A

HF, contraindicated in G6PD deficiency

48
Q

This drug is a URAT1 (urate transporter) inhibitor that enhances uric acid secretion.

A

Lesinurad (Zurampic)

49
Q

Lesinurad (Zurampic) dosing

A

200 mg PO QD

50
Q

Lesinurad is approved for use in combination with _______.

A

XOI

51
Q

Zurampic adverse effects

A

HA, GERD, black box warning in acute renal failure

52
Q

This class of drugs is under investigation for potential use in gout treatment.

A

IL-1 inhibitors (anakinra, canakinumab)

53
Q

Which ARB has the unique property of reducing uric acid reabsorption?

A

Losartan

54
Q

What is first line therapy for gout prophylaxis?

A

low dose colchicine (0.6 mg PO QD or BID)

55
Q

second line therapy for gout prophylaxis

A

low dose NSAID such as naproxen 250 mg PO BID (and PPI where indicated)

56
Q

If first and second line therapy fail to prevent gout attacks as desired, what other option is there?

A

low dose oral CS (prednisone <10 mg/day)

Therapeutics 1 (24 decks)

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