Gout Therapeutics

Question 1

When do you start urate lowering therapy?

Answer 1

After acute attack w/ NSAIDs

Question 2

How long is the treatment for an acute gout attack

Answer 2

if started within 12-36 hours it should take no more than 5-7 days

Question 3

When are NSAIDS not first line?

Answer 3

• elderly
• GI issues
• Renal concerns
• Cardiovascular concerns

Question 4

What are the GI concerns for NSAIDs MOA

Answer 4

• inhibits prostaglandins that are important in gastroprotection
• PPI can be used IF THEY ALREADY HAD GI COMPLICATIONS (secondary prevention)

Question 5

What are the renal concerns for NSAIDs MOA

Answer 5

Ihibits renal vasodilatory PG’s that are important in auto-regulation of blood flow

Do not use
1. 60+
2. Dehydration (vomitting, diarrhea)
3. Diuretics, ACE
4. CHF, heart/kidney disease, HTN
5. CrCL < or equal to 40ml/min
**check serum creatinine before starting dose

Question 6

What are the CV concerns for NSAIDs MOA

Answer 6

NSAIDs cause sodium and fluid retention
- Worsens HTN, risk of stroke

only use if they have STABLE HTN
- naproxen has the least CV side effects

Question 7

When is celecoxib used? and not?

Answer 7

• Good for renal patients
• Protects stomach

Not used in patients with CVS

Question 8

When is colchicine used? why?

Answer 8

1st line when NSAIDs are contraindicated
- slower to work than NSAIDs

Question 9

Explain colchicine dose

Answer 9

Low dose = efficacy as high dose

• low dose has least side effects

Question 10

What are some colchhicine considerations? contraindicated vs reduce dose

Answer 10

Contraindicated
- CrCl <10mL/min
- Bone marrow suspension

Adjust dose
- billiary obstruction, renal impariment
- alcoholism, GI disease
- Dialysis
- Geriatrics
- Dental disease
- Pregnancy section C

Question 11

What drugs not to use with colchicine?

Answer 11

• MYCINS
• AZOLE
• cyclosporine
• grapefruit juice

Question 12

How do corticosteroids work?

Answer 12

2nd line
- upregulate anti-inflammatory gene transcription
- down regulate inflammatory genes transcription

Question 13

When to use oral vs IA injections

Answer 13

oral: multiple joints
IA: 1-2 joints

Question 14

Why is corticosteroids 2nd line

Answer 14

Has numerous long-term uses
- do not use with NSAIDs

Question 15

What is the main thing when first starting ULT? why>

Answer 15

To add low dose anti-inflammatory prophylaxis for 3-6 months
- any change in SUA levels causes a gout attack

Question 16

What qualifies for urate lowering therapy (3)

Answer 16

Any of the following:
1. 1+ Subcutaneous tophi
2. Evidence of radiologic (joint) damage
3. Frequent gout flares (2+ per year)

Question 17

When do you recommend against ULT (2) When do you consider?

Answer 17

Recommend against in
- FIRST gout flare
- Asymptomatic

Consider
- mod-severe (stage 3) kidney disease + elevated serum urate levels

Question 18

When can allopurinol hypersensitivity the most common? Risk factors?

Answer 18

First 60 days of start

Risk factors
- Renal insufficiency
- Thiazide use
- High dose initiation

Question 19

When is allopurinol used

Answer 19

1st line
- for both over-producers and under-producers
- well tolerated side effects

Question 20

Differentiate between allopurinol & febuxostat

Answer 20

Allopurinol
- purine analog

Febuxostat
- non-purine analog
- increase risk of cardiac death
- not usually recommended

Question 21

When to use uricosurics: probenacid (losartan, fenofibrate)

Answer 21

• only for under excreters
• can use with allopurinol
• Do not use if CrCl <50mL/min
• increases uric acid in urine

Question 22

How do uricases (pegloticase, rasburicase) work?

Answer 22

Uricase (urate oxidase) is an enzyme that we do not have normally
- it metabolizes uric acid into allantoin which is easily secreted by the kidneys