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CDM 2 Exam 2 > Lecture 6 - Gout 1 > Flashcards

Lecture 6 - Gout 1 Flashcards

1
Q

Hyperuricemia

A

Elevated Serum Uric Acid

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2
Q

Tophus

A

Calculus contains sodium rate that develops around fibrous tissues around joins, typically in patients with gout

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3
Q

Podagra

A

Painful condition of big toe caused by gout

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4
Q

Uricase

A

enzyme that oxidatively degrade uric acid, thereby catalyzing conversion to soluble allantoin, which is more soluble than uric acid

found in most animals, not in humans

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5
Q

Uricosuric meds

A

Meds given to increase elim of uric acid

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6
Q

Uric Acid Pathway

A

Hypoxanthine (Via Xanthine Oxidase ) -> Xanthine (via Xanthine Oxidase) - > Uric Acid (excreted by kindey, metabolized via rate oxidase in animals)

Gets converted to Allantoin in animals

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7
Q

Uric acid comes from?

A

Metabolism of purines

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8
Q

How is Uric acid eliminated in humans?

A

Gut and Kidney

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9
Q

Hyperuricemia SUA

A

> 7mg at 37C for men

> 6mg at 37C for women

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10
Q

Do all patients with hyperuricemia develop acute gout flares?

A

No

in absence of gout, asymptomatic hyperuricemia does not require treatment

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11
Q

Best description of gout?

A

Patients with gout will have recurrent acute attacks separated by intercritical periods

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12
Q

Risk Factors for Gout

A
  1. Inc age
  2. Male > female
  3. injury
  4. Hyperuricemia** most important
  5. Fasting
  6. Recent srugery
  7. Food/drinks
  8. Meds
  9. Medical conditions
  10. Genetics
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13
Q

Food/Drink risk factors for Gout

A

Food high in purine = red meat
Foods/drinks w/ high fructose corn syrup = soda
Alcohol

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14
Q

Meds that can cause overproduction

A

Cytotoxic chemotherapy

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15
Q

Meds that can cause under excretion

A

Cyclosporine + Tacrolimus
Diuretics (loop/thiazide)
Niacin
Low dose salicylates (< 2g/day)

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16
Q

Medical Condition Risk factors pointed out

A

Overproduction:
Myeloproliferative disorders
Lymphoproliferative disorders

Underexcretion:
Renal insufficiency
Volume depletion
CVD, common Risk factors

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17
Q

Risk Factors: Genetics

A

HGPRT deficiency: Leads to more Guanylic acid, leading to more uric acid

PRPP over activity: can increase Hypoxanthien leading to uric acid

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18
Q

Acute Goute Pathophysiology

A

Uric acid crystals deposit into joint, bringing immune cells that cause them to rupture and perpetuates an inflammatory response

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19
Q

Acute Gout Presentation

A

12-24hrs after exposure to risk factor

lower extremities

redness, swelling, warmth, extreme pain of the joints

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20
Q

Mot common areas for gout attack

A

big toe joint = paragraph

can get in knee, finger, wrists elbows

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21
Q

Difference with pseudo gout?

A

caused by calcium pyrophosphate crystals

can only tell by “tapping joint” looking at fluid after microscope

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22
Q

How to get diagnosis of gout?

A

Tapping joint and looking at fluid under microscope = gold standard

if cant do that, often do clinical diagnosis

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23
Q

Acute Gout management Treatment

A

want to rapidly relive symptoms

prevent recurrent attacks

prevent complications associated with chronic deposition of urate crystals

self limiting, can go away on its own but don’t want to do that

** Dont dx ULT in acute attack **

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24
Q

Nonpharm treatment options of Gout

A

Ice
Rest affected point
Patient education

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25
Q

Pharm treatment options of Gout

A

Colchicine
NSAIDs
Steroids (systemic/intra-articular)
IL-1 antagonists

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26
Q

FDA approved NSAIDs for gout

A

Indomethacin (Indocin)
Naproxen (Naprosyn)
Sulidac (Clinoril)

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27
Q

NSAIDs ADR

A

Inc BP, NA/Water retention, gastritis, GI bleeding

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28
Q

NSAIDs CI

A

Hx of allergy
HF
Renal Insufficiency
Hx of previous GI

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29
Q

NSAIDs DI

A 
ACE/ARBs
Cyclosporine
Tacrolimus
Tenofovir
Lithium
Anti-platelet/anticoag
Corticosteroids
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30
Q

NSAIDs monitoring efficacy

A

efficacy, lower pain, reduced number of flairs

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31
Q

NSAIDs monitoring safety

A 
CBC
LFTs
SCr
Fecal occult blood test
Black tarry stools
BP
Edema
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32
Q

Corticosteroids MOA

A

Synthetic glucocorticoid analog used for anti-inflammatory effects

33
Q

Corticosteroids ADR

A

Acute: Hypoglycemia, leukocytosis, fluid retention, impaired wound healing, GI, insomnia, Hypertension

Chronic: HPA axis suppression, osteoporosis

34
Q

Corticosteroids Precautions

A

Infection
DM
Peptic ulcer disease

35
Q

Corticosteroid DI

A

Strong CYP3A4 inhib
Fluoroquinolone
NSAIDs
anti-hyperglycemic agents

36
Q

Corticosteroid Pt education

A

monitor BG if DM

Take w/ food or milk to minimize GI upset

37
Q

Colchicine MOA

A

May interferon w/ intracellular assembly of the inflammasome complex present in neutrophils and monocytes that mediates the activation of IL-1B

38
Q

Prophylaxis Colchicine Dose

A

0.6mg or BID for ~6 months

Req renal adjustment in bad renal impairment

adjustment in severe hepatic impairment

39
Q

Treatment of gout Flair Colchicine Dose

A

7 days at 1.2mg once, then 0.6mg one hour later

Req renal adjustment in really bad renal impairment

adjustment in severe hepatic impairment

40
Q

If combo Hepatic/renal impairment can you use Colchicine?

A

nah

41
Q

Colchicine Side effects

A

GI = diarrhea
Blood dyscrasuas
Neuromuscular toxicity

42
Q

Colchicine CI

A

Patients w/ renal or hepatic impairment should not use w/ PGP or Strong CYP3A4 inhibitor

43
Q

Colchicine DI

A

Strong CYP3A4, PGP inhib

Statins & Fenofibrates

Req dose adjustments if current on meds, or if recently on meds (within last 14 days)

44
Q

Colchicine Monitoring

A

Efficacy: signs/symptoms of gout, dec gout flares

Safety: CBC, signs/symptoms, GI

45
Q

Colchicine Pt education

A

Appropriate dosing
ADE
Avoid Grapefruit juice

46
Q

Anakinra Brand

A

Kineret

47
Q

Canakinumab brand

A

Illaris

48
Q

rilonacept Brand

A

Arcalyst

49
Q

Which IL-1 agent only used for prophylaxis?

A

Rilonacept (Arcalyst)

50
Q

IL-1 Antagonist SE

A

injection site reactions
Neutropenia
Hypersensitivity reactions
infectious disease

51
Q

IL-1 Antagonist CI

A

Hypersensitivity

52
Q

IL-1 Antagonist DI

A

Immunosuppressants

Live vaccines

53
Q

IL-1 Antagonists monitoring

A

Neutrophil count
Temp
Signs of infections

54
Q

IL-1 antagonist Pt education

A 
Report signs of infection
Screen for TB
avoid live vaccines
SE
proper injection
55
Q

IL-1 Antagonists

A

Anakinra (Kineret)
Canakinumab (Illaris)
Rilonacept (Arcalyst)

56
Q

Corticosteroids

A

Prednisone (Deltasone, Prednicort)
Methylprednisolone (Medrol)
Triamcinolone IM (Kenalog)
Triamcinolone acetonide intraarticular

57
Q

How to select Gout agent for patient?

A 
Patient Preferences
Current attack
Response to current therapy
Comorbid conditions
DI
Cost of therapy
58
Q

Acute Gout Med to avoid in CKD

A

NSAIDs
Cox-2 inhibitor
Colchicine

59
Q

Acute Gout med to avoid in Liver disease

A

NSAIDs
Cox-2 inhibitor
Colchicine

60
Q

Acute Gout med to avoid CHF

A

NSAIDs
Cox-2 inhibitor
Corticosteroids

61
Q

Acute Gout med to avoid HTN

A

NSAIDs
Cox-2 inhibitor
Corticosteroids

62
Q

Acute Gout med to avoid ASCVD

A

NSAIDs

Cox-2 inhibitor

63
Q

Acute Gout med to avoid PUD

A

NSAIDs
Cox-2 inhibitor
Corticosteroids

64
Q

Acute Gout med to avoid Diabetes

A

Corticosteroids

65
Q

Acute Gout med to avoid Infection/Infection Risk

A

Corticosteroids

IL-1 antagonists

66
Q

Acute Gout med to avoid Geriatric Patients

A

Indomethacin

67
Q

1st line therapy for Acute Gout

A

NSAIDs
Colchicine
Glucocorticoids

All preferred over IL-1 antagonists

Low dose Colchicine > High Dose

IL-1 used if pts cant tolerate or take others

68
Q

1st line therapy for Acute Gout

A

NSAIDs
Colchicine
Glucocorticoids

All preferred over IL-1 antagonists

Low dose Colchicine > High Dose

IL-1 used if pts cant tolerate or take others

69
Q

Treatment Goals for chronic Gout?

A

Maintain SUA of < 6mg/dL

70
Q

Strongly Recommend to Start ULT

A

> 1 tophi

Radiographic damage attributable to gout

frequent Gout flares > 2/yrs

71
Q

Conditionally Recommended to Start ULT

A

Pts w/ >1 flare but have <2/yr

pts experiencing 1st flare and have > Stage 3 CKD, SUA > 9 or urolithiasis

72
Q

Patients recommended against Start ULT

A

pts experiencing 1st flare with exceptions

Asymptomatic hyperuricemia

73
Q

What to do before starting ULT?

A

1st initiate prophylactic therapy for mobilization flares

Low dose colchicine
NSAIDs (give with PPI due to length on them ~ 6 month)
Corticosteroids

74
Q

How long should Prophylactic therapy last for mobilization therapy before ULT?

A

3-6 months

possible to extend if still experiencing flares

75
Q

Allopurinol MOA

A

Xanthine Oxidase inhibitors

76
Q

Allopurinol Dosing

A

Start 50 or 100mg daily (depend on renal function), titrate up by 50-100mg every 2-5 weeks until goal of SUA < 6mg/dL

Doses > 300mg often given in divided doses

Max daily Dose = 800mg

77
Q

When to use 50mg Allopurinol Dose

A

Stage 4 CKD or higher

78
Q

when to use 100mg Allopurinol Dose

A

Everyone, incl blew Stage 4 CKD

CDM 2 Exam 2 (16 decks)

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