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PHRM 825 > PHRM 825: Gout - Wahl > Flashcards

PHRM 825: Gout - Wahl Flashcards

1
Q

What is gout caused by?

A

A deposition of monosodium urate crystals in the synovial fluid or tissues

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2
Q

What disease is gout secondary to?

A

Hyperuricemia

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3
Q

What serum urate level diagnoses hyperuricemia?

A

> or = 6.8 mg/dL

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4
Q

What are the two clinical phases of gout?

A
  • Intermittent acute attacks

- Chronic tophaceous gout

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5
Q

What 5 disease states increase your risk for gout?

A
  • HNT
  • T2DM
  • Obesity
  • Metabolic syndrome
  • CKD
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6
Q

What dietary factors increase your risk for gout?

A
  • Alcohol
  • High in purines (meat and seafood)
  • High fructose beverages
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7
Q

What 5 medications increase your risk for gout?

A
  • Thiazide diuretics
  • Loop diuretics
  • Niacin
  • Calcineurin inhibitors
  • Aspirin (<1 g/day)
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8
Q

What 3 medication classes are used during an acute gout attack?

A
  • NSAIDs
  • Colchicine
  • Corticosteroids
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9
Q

What NSAIDs are FDA approved for gout attacks?

A
  • Naproxen
  • Sulindac
  • Indomethacin
  • Celecoxib (COX-2 only)
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10
Q

What is the dosing for Naproxen for an acute gout attack?

A

250mg PO tid

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11
Q

What is the dosing for Sulindac for an acute gout attack?

A

750mg initially, then 250mg q8h

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12
Q

What is the dosing for Indomethacin for an acute gout attack?

A

200mg PO bid

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13
Q

What is the MOA of colchicine?

A

Disruption of microtubule formation – Prevents activation, migration, and degranulation of neutrophils which propagate immune response in affected joint

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14
Q

What is the dosing for Colchicine for an acute gout attack?

A
  1. 2 mg load once, then 0.6 mg an hour later
    * resume/start maintenance 12 hours later

If on HD, 0.6mg once, do not re-dose for 2 weeks

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15
Q

What 5 meds interact with colchicine?

A
  • Protease inhibitors
  • Azole antifungals
  • Clarithromycin
  • Verapamil
  • Statins
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16
Q

When are corticosteroids used for acute gout attacks?

A
  • NSAID/colchicine intolerance
  • Polyarticular involvement
  • Resistant cases
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17
Q

What is the dosing for prednisone for an acute gout attack?

A
  • 0.5 mg/kg/day for 5-10 days

- 0.5 mg/kg/day for 2-5 days then taper for 7-10 days

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18
Q

What is the dosing for methylprednisolone for an acute gout attack?

A

21 day dose pack

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19
Q

What is the dosing for Triamcinolone for an acute gout attack?

A
  • 60 mg IM once, then oral prednisone

- 2.5-40 mg intra-articular injection once

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20
Q

5 adverse effects of corticosteroids

A
  • GI toxicity (bleed/PUD)
  • N/V/D
  • Hyperglycemia
  • Weight gain and increased appetite
  • Fluid retention
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21
Q

Adverse effects of colchicine

A
  • GI (N/V/D)
  • Bone marrow suppression
  • Neuromuscular
22
Q

Adverse effects of NSAIDs

A
  • GI (bleed/gastritis)
  • Renal (AKI)
  • Cardiovascular (Sodium/fluid retention, edema)
23
Q

Which 2 treatment options for acute gout attack should not be given together?

A

NSAIDs and Oral corticosteroids (GI toxicity)

24
Q

When is acute gout attack prophylaxis indicated?

A

When urate lowering therapy is being initiated

25
Q

What are the goals of therapy for acute gout attacks?

A
  • Relieve attack (preferable withing 24 hours)
  • Continue urate lowering therapy (ULT)
  • Patient education
26
Q

What are the goals of therapy for chronic gout management?

A
  • Prevent future attacks

- Reduce serum uric acid levels to < or = 6 mg/dL (or 5 in severe cases)

27
Q

What constitutes a severe case of chronic gout management?

A
  • Polyarticular involvement (4 or more joints)

- Tophi

28
Q

What are 4 indications for ULT?

A
  • Frequent acute attacks (2 or more/year)
  • Tophi on exam or imaging
  • Uric acid > 10mg/dL
  • CKD stage 2 or worse
29
Q

ULT monitoring

A
  • every 2-5 weeks during initiation

- Every 6 months once goal <6 mg/dL achieved

30
Q

What are 3 first-line ULT?

A
  • Xanthine oxidase inhibitors
  • Allopurinol
  • Febuxostat
31
Q

What are 2 second-line ULT?

A
  • Uricosurics

- Probenecid

32
Q

What are 2 third-line ULT?

A
  • Uricase agents

- Pegloticase

33
Q

What is the typical first choice xanthine oxidase inhibitor?

A

Allopurinol

34
Q

Common Allopurinol adverse effects

A
  • GI upset
  • Skin rash
  • Leukopenia
  • Thrombocytopenia
  • Increased LFTs
  • HA
35
Q

Allopurinol drug interactions

A
  • Warfarin
  • Mercaptopurine and azathioprine
  • Pegloticase
36
Q

What xanthine oxidase inhibitor is chosen when the patient has an allopurinol intolerance?

A

Febuxostat

37
Q

Common Febuxostat adverse effects

A
  • Rash
  • Nausea
  • Abnormal LFTs
38
Q

MOA of probenecid

A

Inhibits reabsorption of uric acid in convoluted tubule of kidney

39
Q

When is Probenecid used for chronic management of gout?

A
  • Documented underexcretion of urate
  • Patient resistant/intolerant to allopurinol
  • Cannot reach target urate on monotherapy with XOI
  • May also be added to allopurinol
40
Q

Probenecid adverse effects

A
  • Rash, flushing, HA
  • GI upset
  • Stone formation (increase fluid intake)
41
Q

Probenecid contraindications

A
  • History of uric acid kidney stones
  • Concomitant salicylates, especially >325mg/day
  • Overproducers of uric acid
  • CrCl <50mL/min
42
Q

MOA of Uricase agents

A

Metabolizes uric acid to allantoin (excreted 10x more effectively in the urine)

43
Q

When are uricase agents used for chronic management of gout?

A
  • Last-line agent
  • Indicated for refractory chronic gout (patients with significant disease burden and refractoriness to (or intolerance of) conventional urate lowering therapy)
44
Q

Adverse effects of Pegloticase

A
  • Infusion reactions
  • Anaphylaxis
  • Nephrolithiasis
  • Arthralgias
  • HF exacerbation
  • Nausea
45
Q

Contraindications/cautions for Pegloticase

A
  • G6PD deficiency

- HF

46
Q

MOA of Lesinurad

A

URAT1 inhibitor (enhances uric acid excretion)

47
Q

When is Lesinurad used?

A

In combo with XOI

48
Q

Adverse effects of Lesinurad

A
  • Black box warning: acute renal failure (monotherapy)
  • HA
  • GERD
49
Q

Fenofibrate MOA

A

Increases clearance of both hypoxanthine and xanthine (decreases urate levels 20-30%)

50
Q

Losartan MOA

A

Inhibits tubular reabsorption of uric acid increasing urinary excretion

PHRM 825 (36 decks)

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