Gout Therapeutics Flashcards
what are the main causes of gout
over production of uric acid or underexcretion of uric acid
what can cause overproduction of uric acid
Enzyme variability
Cytotoxic medications
Increase dietary intake of purines
chronic alcohol intake
what can cause under excretion of uric acid
dehydration
insulin resistance
acute alcohol intake
medications
what are the 3 main meds that lead to gout
Diuretics
Cytotoxic drugs
Salicylates
Presentation of acute gout
-podagra
-UA deposits elsewhere
-fever
-intense pain
-swelling at joints
what UA level is elevated
above 6.8
what are complications of acute gout
-Tophi
-Nephrolithiasis
-Nephropathy
What is the general treatment approach for treating gout
-treat pain
-use ULT to prevent recurrence
-anti-inflammatory prophylaxis
Non pharm gout treatment
modify risk factors
applying ice
no supplements
What are the NSAIDs for gout
Indomethacin
Naproxen
Ibuprofen
Sulindac
Tapering for prednisone
7-10 days
What is the MOA of colchicine
disrupts cytoskeletal functions by inhibiting tubules
when to administer colchicine for acute attack
within 24 hours
what is the colchicine dosing
Day 1: 1.2mg PO once then 1 hour later
Day 2+: 0.6mg BID until attack resolves
Colchicine AEs
Neutropenia
Axonal neuromyopathy
Do you renally adjust colchicine
yes
Colchicine dose with CrCl less than 30
1.2mg onset, 0.6mg 1 hour later (once)
tx should be repeated no more than once every 2 weeks
Colchicine dose with dialysis
single 0.6mg dose
tx should not be repeated more than once every 2 weeks
When should you switch from colchicine
less than 50% improvement in pain in 24hrs
What to do with inadequate colchicine response
switch agents
add 2nd agent
What is the pill-in-pocket method
using abortive agent when gout onset comes on
Diet changes for gout
DASH diet
avoid foods with saturated fats and sweetened bevs/food
alcohol restriction
limit high fructose corn syrup and organ meats
when to start ULT
more than 2 gout flares/year
tophus
first flare w/ either CKD, uric acid above 9, urolithiasis
who is not a candidate for ULT
asymptomatic hyperuricemia
first gout attack w/o risk factors
what are risk factors for gout
male
post-menopausal
elderly
obesity
diet & alc intake
sedentary
renal impairments
when to initiate ULT
wait 2 weeks after acute attack
how long should ULT last
life long
what UA level should you target for ULT
less than 6
what is first line for ULT
Allopurinol and Febuxostat
what is the initial dose of allopurinol
100mg PO daily
how to titrate allopurinol
every 2-4 weeks in 100 mg increments
what is the max dose of allopurinol
800mg/day
what is the initial dose of Febuxostat
40mg daily
how to titrate febuxostat
titrate to 80mg daily
max dose of febuxostat
max dose 120mg/day
should you renally adjust allopurinol
yes
allopurinol dose eGFR less than 60
initial dose 5mg
titrate slowly
what are the DDIs with allopurinol
loop and thiazide diuretics
warfarin
what is the severe reaction to allopurinol
SJS and TEN
what gene should be tested for allopurinol
HLA-B*5801
main counseling for allopurinol
take this med even when you do not have gout symptoms
what is second line ULT
Probenecid
Probenecid initial dose
250mg PO BID x1-2 weeks up to 500mg BID
Probenecid titration
Titrate by 500mg increments every 1-2 weeks
Probenecid max dose
2g/day
Probenecid ADR
Urolithiasis
what should you consider before probenecid
G6PD deficiency
not recommended in eGFR less than 60
what DDIs are there for probenecid
antibiotics
what is 3rd line for ULT
Pegloticase
when to use Pegloticase
used in severe gout and hyperuricemia
patients not responsive to subcutaneous tophi
what formulation is pegloticase
IV infusion
what is the dose of pegloticase
8mg IV every 2 weeks
Pegloticase pearls
patients may develop antibodies
When to start gout prophylaxis
initiating ULT
what is the duration of gout attack prophylaxis
first 3-6 months of ULT initiation
what agents can be used for gout prophylaxis
NSAIDs
Prednisone
Colchicine
Colchicine prophylactic dose
0.6mg once or twice daily
prophylactic colchicine dose with CrCl less than 30
0.3mg daily
prophylactic colchicine dose on dialysis
0.3mg twice weekly
