Gout Therapeutics Flashcards
When do you start urate lowering therapy?
After acute attack w/ NSAIDs
How long is the treatment for an acute gout attack
if started within 12-36 hours it should take no more than 5-7 days
When are NSAIDS not first line?
- elderly
- GI issues
- Renal concerns
- Cardiovascular concerns
What are the GI concerns for NSAIDs MOA
- inhibits prostaglandins that are important in gastroprotection
- PPI can be used IF THEY ALREADY HAD GI COMPLICATIONS (secondary prevention)
What are the renal concerns for NSAIDs MOA
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
What are the CV concerns for NSAIDs MOA
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
When is celecoxib used? and not?
- Good for renal patients
- Protects stomach
Not used in patients with CVS
When is colchicine used? why?
1st line when NSAIDs are contraindicated
- slower to work than NSAIDs
Explain colchicine dose
Low dose = efficacy as high dose
- low dose has least side effects
What are some colchhicine considerations? contraindicated vs reduce dose
Contraindicated
- CrCl <10mL/min
- Bone marrow suspension
Adjust dose
- billiary obstruction, renal impariment
- alcoholism, GI disease
- Dialysis
- Geriatrics
- Dental disease
- Pregnancy section C
What drugs not to use with colchicine?
- MYCINS
- AZOLE
- cyclosporine
- grapefruit juice
How do corticosteroids work?
2nd line
- upregulate anti-inflammatory gene transcription
- down regulate inflammatory genes transcription
When to use oral vs IA injections
oral: multiple joints
IA: 1-2 joints
Why is corticosteroids 2nd line
Has numerous long-term uses
- do not use with NSAIDs
What is the main thing when first starting ULT? why>
To add low dose anti-inflammatory prophylaxis for 3-6 months
- any change in SUA levels causes a gout attack
What qualifies for urate lowering therapy (3)
Any of the following:
1. 1+ Subcutaneous tophi
2. Evidence of radiologic (joint) damage
3. Frequent gout flares (2+ per year)
When do you recommend against ULT (2) When do you consider?
Recommend against in
- FIRST gout flare
- Asymptomatic
Consider
- mod-severe (stage 3) kidney disease + elevated serum urate levels
When can allopurinol hypersensitivity the most common? Risk factors?
First 60 days of start
Risk factors
- Renal insufficiency
- Thiazide use
- High dose initiation
When is allopurinol used
1st line
- for both over-producers and under-producers
- well tolerated side effects
Differentiate between allopurinol & febuxostat
Allopurinol
- purine analog
Febuxostat
- non-purine analog
- increase risk of cardiac death
- not usually recommended
When to use uricosurics: probenacid (losartan, fenofibrate)
- only for under excreters
- can use with allopurinol
- Do not use if CrCl <50mL/min
- increases uric acid in urine
How do uricases (pegloticase, rasburicase) work?
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
