Pain/Related Conditions: Gout Flashcards
Gout is caused by
buildup of uric acid crystals in the joints
Gout attack info
usually sudden onset
occurs in one joint, most often big toe
Risk factors for Gout
Male sex
obesity
excessive alcohol (mostly beer)
HTN
CKD
Lead intoxication
old age
meds that inc UA
Foods to avoid in Gout
organ meats
high fructose corn syrup
alcohol
Drugs used to treat acute pain in Gout
Colchicine
Steroids
NSAIDs
Drugs used to prevent future Gout attacks
Allopurinol (preferred) or febuxostat = Xanthine oxidase inhibitors
Colchicine Contraindications
dont use in combo with P-gp or strong CYP3A4 inhibitor with renal/hepatic impairment
Colchicine (Colcrys) warnings
Myelosuppression
inc myopathy risk if suing statins, gemfibrozil, verapamil, diltiazem, cyclosporine
Colchicine side effects
Diarrhea
nausea
myopathy
neuropath
Colchine dosing notes
start within 36hrs of symptom onset, wait 12hrs till after txm dose before starting prophylaxis dose
NSAIDs for Gout
Indomethacin (Indocin)
Naproxen (Aleve)
Celecoxib (Celebrex)
Steroids for Gout
Prednisone/Prednisolone
Methylprednisolone
Steroids SE
inc BG
inc BP
insomnia
Inc appetite
Colchicine drug interactions
CYP3A4 inhibitors = clarithromycin
P-gp inhibitors = cyclosporine
fatal toxicity can occur
Who should start Uric Lowering therapy
pts with multiple or frequent Gout attacks
evidence of joint damage
have tophi
What gene should be screened for in pts at high risk of allopurinol hypersensitivity reactions
HLA-B* 5801 allele
Alternative Xanthine oxidase inhibitor (XOI) if cant use allopurinol
Febuxostat
second line txm if XOI are contraindicated
Probenecid
How does Probenecid work?
inhabits reabsorption of uric acid, increasing excretion
req good renal function
How does allopurinol work
blocks xanthine oxidase enzyme, stopping production of Uric Acid and produces non-toxic end product
lower dose if moderate/severe CKD
Uric acid goal for gout?
< 6mg/dL
Options for when UA isn’t at goal
Lesinurad = taken with XOI
pegloticase = used for refractory, severe disease
Pegloticase MOA
recombinant Uricase
inc uric acid conversion to allantoin
Allopurinol warnings
hypersensitivity reactions, severe rash (SJS/TEN DRESS), screen for HLA-B*5801 b4 start in high risk patients (Asian)
Allopurinol side effects
Rash
acute gout attacks
nausea
diarrhea
Notes on Allopurinol
use with colchicine 0.6mg QD/BID or another NSAID for 3-6 months at start
Febuxostat Boxed warnings
inc risk of CV death compared to allopurinol in CVD patient, use only if cant use allopurinol
Febuxostat Contraindications
Dont use with mercaptopurine or azathioprine
Febuxostat warnings
Hepatotoxicity
serious skin reactions = SJS/TEN, DRESS
Febuxostat side effects
rash
nausea
inc LFTs**
Febuxostat max daily dose if CrCl < 30
40mg QD
Lesinurad (Zurampic) should only be started in pts with CrCl above?
> 45 mL/min
Pegloticase Boxed warnings
Anaphylactic reactions: monitor and premedical w/ antihistamines and steroids
Pegloticase Contraindications
G6PD deficiency
Which Gout meds should Pegloticase not be used with?
Dont use in combo with allopurinol, febuxostat or probenecid
Other uses for probenecid?
inc beta lactam concentration
Tumor lysis syndrome
when cells get ‘lysed’, they release purines into blood and quickly converted to UA
can cause a bunch of issues, potentially life threatening
What’s used for Tumor Lysis Syndrome
Rasburicase (Elitek)
Contraindicated: G6PD deficiency
