Lecture 7.1 - Gout 2

Question 1

Allopurinol Hypersensitivity Syndrome Manifestation

Answer 1

Rash, chills, fever, leukopenia, leukocytosis, eosinophilia, and pruritus

Maybe severe and fatal ( hepatotoxicity, vasculitis, SJS and TEN)

Question 2

AHS prevention

Answer 2

HLA-B*5801 screening

only in high risk, and those who are positive we won’t use allopurinol

Question 3

AHS management

Answer 3

Discontinue allopurinol at 1st sign of rash

Supportive care

Question 4

AHS mortality rate

Answer 4

~ 25%

Rare tho

Question 5

Allopurinol CI

Answer 5

Allopurinol sensitivity

concurrent didanosine use

Question 6

Allopurinol DI

Answer 6

Didanosine

Azathioprine + 6-mercaptourine (MUST reduce dose of both when used in combo with Allopurinol)

Theophylline
Pegloticase
Loop/thiazide diuretics

Question 7

Allopurinol monitoring

Answer 7

Efficacy: SUA every few weeks till goal
Safety: HLA-B*5801 test prior to start in high risk pops

Question 8

High risk pops for HLA-B*5801

Answer 8

Han chinese
Korean
Thai
AA

Question 9

Allopurinol patient education

Answer 9

Signs and symptoms of allergic reaction
HLA testing
How to use

Question 10

Febuxostat (Uric) MOA

Answer 10

non-purine inhib of XAI leading to reduced production of uric acid

Question 11

Febuxostat ADR

Answer 11

Hepatic: abnormal LFTs
GI: nausea
Rheumatologic: Gout flares
Rash, Arthralgia

Question 12

Febuxostat CI

Answer 12

concomitant use of Azathioprine or 6-mercaptopurine

Question 13

Febuxostat Precuations

Answer 13

Acute gout flare
CVD events
Hepatoxicity
Serious skin reactions

Question 14

Febuxostat DI

Answer 14

Azathioprine or 6-mercaptourine
Theophylline
pegloticase
didanosine

Question 15

Febuxostat Monitoring

Answer 15

Efficacy: SUA after 2 weeks of treatment + periodically

Safety: LFTs at BL and if signs of hepatic injury

Question 16

Febuxostat Pt education

Answer 16

use
ADR
dont use with azathioprine or 6-MP

Question 17

Study that chose Allopurinol > Febuxostat in CV patients?

Answer 17

CARES Trial

Febuxastat as Black Box warning due to study

Question 18

Uricosurics

Answer 18

Probenecid
Sulfinpyrzone
Benzbromerone
Losartan

Question 19

Probenecid MOA (Benamid)

Answer 19

Competitively inhibits the postsecretory renal proximal tubular reabsorption of uric acid

Question 20

When to avoid Probenecid?

Answer 20

CrCl < 50

Question 21

Probenecid SE

Answer 21

Most common = GI, uric acid nephrolithiasis (Uric Acid kidney stones)

Hemolytic Anemia (in G6PD deficiency in Mediterranean & AA)

Question 22

Probenecid CI

Answer 22

HX of urolithiasis
Overproducer of uric acid
Hypersensitivity to it
Small & Large dose salicylate therapy
Blood dyscrasias
< 2 yrs old
initiation during acute gout attack

Question 23

Probenecid Precautions

Answer 23

Disease related: G6PD, PUD, Renal impairment

Drug-related: Methotrexate, penicillin, salicylate

Question 24

Probenecid DI

Answer 24

Salicylates
Penicillins/Cephalosporins/Carbapenems
Methotrexate
Pegloticase

Question 25

Probenecid Pt education

Answer 25

inc fluid intake

Question 26

Probenecid place in therapy?

Answer 26

Add on therapy to XOI in patients not controlled on single agent

XOI is preferred over probenecid for those with > Stage 3 CKD

Question 27

Losartan place in therapy?

Answer 27

Add on in patients with HTN who are already on XOI and not controlled

Question 28

Is probenecid for Overproducers or Underexcretors?

Answer 28

Under excreters

Question 29

Pegloticase (Krystexxa) MOA

Answer 29

pealed recombination modified mammalian rate oxidase (Uricase)

Question 30

What to know about Krystexxa infusion?

Answer 30

Premeditate with corticosteroid and antihistamine pre-medication

Question 31

Pegloticase (Krystexxa) SE

Answer 31

Gout flares
Infusion reactions
Nausea 
Vomiting
Bruising
Nasopharyngitis 
Constipation
Chest pain
Anaphylaxis (Black Box for this)

Question 32

Pegloticase (Krystexxa) CI

Answer 32

G6PD deficiency

Question 33

Pegloticase (Krystexxa) Precautions

Answer 33

Anaphylaxis
Infusion reactions
Gout Flares
CHF

Question 34

When should you stop Krystexxa?

Answer 34

When SUA above 6mg/dL for 2 infusion in a row

Question 35

Place of use for Krystexxa

Answer 35

used in patients who continue to have elevated SUA > 6mg/dL, and either frequent flares (> 2/yr) or non resolving subcutaneous tophi

Question 36

Chronic ULT Medication selection

Answer 36

1. Depends on response to therapy, tolerability
2. Genetics
3. Co-morbid conditions
4. DI
5. Cost of therapy

Question 37

ULT guidelines

Answer 37

1. Allopurinol is preferred to all other ULT. should be imitated at low doses, and intesified to SUA < 6 mg/dL
2. If pt is not responding to XOI at max tolerated or FDA approved dose, change to another OXI over adding on a uricosuric agent
3. Swapping ULT to pegloticase strongly recommended for those in whom interventions have been unable to achieve SUA target and continue to have frequent flares or subcu top
4. continue ULT indefinitely

Question 38

Gout self Care

Answer 38

can reduce SUA ~ 10-18%

1. consider alone or in combo with pharm therapy
2. smoking cessation
3. patient ed
4. Hydration
5. exercise
6. weight loss
7. avoidance of risk factors (dietary/meds)

Question 39

Medication Risk factors gout

Answer 39

HCTZ = swap to alternative hypertensive if possible
Losartan = preferred anti hyper when possible
Low dose aspirin= dont stop if recommended in pt
Fenofibrate = dont swap to or add in pts with gout