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PR3154 > IC17 - Gout > Flashcards

IC17 - Gout Flashcards

1
Q

What is gout?

A

It is a disease caused by

  1. Imbalances in purine metabolism
  2. Deposition of monosodium urate (MSU) crystals in articular & periarticular tissues
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2
Q

List 2 factors that are associated with gout.

A
  1. Obese
  2. Male
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3
Q

What are the two reasons for gout that appears in male < 30 yo & premenopausal women.

A
  1. Inherited enzyme defect
  2. Presence of renal disease.
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4
Q

Briefly outline the pathophysiology of gout.

A
  1. Over-production of uric acid due to metabolism deficit and conditions that increase cell turnover & purine generation
  2. Under-excretion of uric acid
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5
Q

Describe the presentation of gout.

A
  1. Monoarticular (1st metatarsophalangeal joint of great toe)
  2. Wakes up from sleep by pain
  3. Severe pain x several hours
  4. Swelling and discomfort continues day to weeks thereafter
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6
Q

How is diagnosis made for gout?

A

Presence of monosodium urate crystals in synovial fluid (joint aspirate) and tissue sections of tophaceous deposits

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7
Q

What are the four stages of gout?

A
  1. Asymptomatic hyperuricemia
  2. Acute gout
  3. Inter-critical phase
  4. Chronic gout
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8
Q

What are the treatment available for acute gout?

A

Colchicine
NSAIDs
Corticosteroids (Intraarticular can be given if patient cannot take PO medications)

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9
Q

What are the treatment available for chronic gout?

A
  1. Allopurinol
  2. Febuxostat
  3. Probenecid
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10
Q

How fast should acute flares be treated?

A

Within 24 hours

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11
Q

What are the considerations for ULT use if flare is not resolved?

A
  1. Reduce risk of not returning for tx
  2. Patients may be highly motivated for tx
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12
Q

When is ULT usually given for acute flares?

A

If indicated and only after resolution of symptoms

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13
Q

Can the patient be continued on ULT during acute flare?

A

Yes (if patient is already on ULT)

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14
Q

What is the non-pharmacological approach for acute flares?

A

Topical Ice

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15
Q

What are the common side effects of colchicine?

A

N/V, diarrhea

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16
Q

What is the consideration for use of colchicine in renal impaired patients?

A

Reduce dose as toxicity will be increased at normal dose

17
Q

Which group of renal impaired patients should not use NSAIDs or COX2?

A

CrCI < 30ml/min

18
Q

What is the treatment target for gout when using ULT?

A
  1. Non-tophaceous gout < 360 umol/L
  2. Tophaceous gout < 300 umol/L
19
Q

List two ULT that inhibits xanthine oxidase and is used in chronic gout.

A

Allopurinol (100 to 800mg/day)
Febuxostat (40 or 80mg OD)

20
Q

What are some considerations for use of allopurinol in gout?

A
  1. Lower dose in renal impairment
  2. Risk of SCAR
21
Q

What are some considerations for use of febuxostat in gout?

A
  1. Liver metabolism
  2. Use w caution in HF & CHD
22
Q

List one medication that blocks URAT1 and GLUT9 inhibitor and is used in chronic gout.

A

Probenecid (500 to 3000mg/day)

23
Q

What are some considerations for use of probenecid in gout?

A
  1. Not recommended in renal impairment (CrCl < 50 ml/min)
  2. Contraindicated in urolithiasis
  3. Not effective in CKD
24
Q

How is allopurinol dosed?

A
  1. Start ≤ 100 mg/day [lower in CKD stage > 3 e.g. ≤ 50 mg/day]
  2. Increase 50 to 100 mg every 2-8 weeks
  3. Maintenance: > 300 mg/day [renal impairment ok]
  4. Max dose: 800-900 mg/day [normal renal only]
25
Q

How is febuxostat dosed?

A
  1. Initiation: < 40 mg/day
  2. Titration: 80 mg/day if treatment target not met after 2-4 weeks
26
Q

How is probenecid dosed?

A
  1. Initiation: 250 mg BD x 1 week, then 500 mg BD
  2. Titration: 500 mg every 4 weeks as tolerated if smx not controlled
  3. Usual maintenance: < 2 g/day
27
Q

What is one counselling point that should be conveyed to patients on probenecid?

A

Keep hydrated (> 2L of water) to prevent kidney stones from forming

28
Q

When is genotyping for HLA*B-5801 needed for allopurinol?

A

For patients at higher risk of allopurinol-induced SCAR e.g. renal impairment or older age.

29
Q

What can be used for prophylaxis against acute flares together with ULT?

A

Anti-inflammatory prophylaxis such as
1. Colchicine 0.5mg OD
2. Low dose oral NSAID/ Coxib (e.g. Celecoxib 200mg OD)
3. Low dose oral corticosteroid (e.g prednisolone <5 to 7.5mg OD)

30
Q

What is the duration for prophylaxis against acute gout flares?

A

3 to 6 months

31
Q

What is the treatment duration for use of ULT?

A

None. Depends on patients’ preference

32
Q

What is considered clinical remission for gout?

A

No flares for > 1 year and no tophi

33
Q

List 4 non-pharmacological methods for gout.

A
  1. Limit alcohol intake
  2. Limit purine-rich foods
  3. Limit high-fructose corn syrup
  4. Weight management
34
Q

Patient has gout and is on hydrochlorothiazide for hypertension, what can be done for him?

A

Change to losartan or enalapril/ captopril as they have uricosuric effects.

35
Q

Should low dose aspirin therapy be stopped for gout patients?

A

No

36
Q

Patient has gout and is on cholesterol lowering agents, what can be done for him?

A

No change needed. Do not switch to fenofibrate

PR3154 (16 decks)

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