Rheumatology Flashcards
When to initiate ULT?
if with 1 or more subq tophi
radiographic damage
frequent flares (more than or equal to 2/year)
conditional if >1 but infrequent flares (<2/yr); first flare except CKD stage 3 or higher, SU >9 mg/dl, urolithiasis
What is the first line ULT
Allopurinol including CKD stage 3 or higher
Start at low dose < or equal 100 mg/day or < 40 mg /day febuxostat
Is ULT recommended in patients with asymptomatic hyperuricemia?
Conditionally recommended against
What is the preferred first-line agent?
Allpurinol for all patients including with moderate-to-severe CKD stage 3 or higher
> 300 mg/day up to 800 mg/day
either allopurinol or febuxostat over probenecid for patients with mod-sev CKD (stage 3 or higher)
Is peglotinase a first line therapy of choice for gout?
It is recommended agaisnt
What is the starting treatment for patients with CKD (stage 3 or higher)
low dose allopurinol < or equal to 100 mg/day or febuxostat of < or equal to 40 mg per day
Is antiinflammatory prophylaxis therapy recommended?
Yes. colchicine, NSAID, prednisone or prednisolone is recommended over no antiinflammatory prophylaxis therapy
Up to how long is concomitant antiinflammatory prophylaxis is given?
3-6 months over < 3 months with ongoing evaluation and continued prophylaxis is needed if the patient continues to experience gout flares
When is ULT be given? during gout flare or later?
It is indicated while the patient is experiencing gout flare rather than starting ULT after the gout flare since it has conceptual benefits which is lowering the risk of patient not returning for ULT treatment
Can you initiate ULT in patients with gout experiencing their first gout flare?
It is conditionally recommended against
What strategy is recommended to achieve a target SU?
treat-to-target strategy which means dose titration and subsequent dosing guided by seria SU over a fixed=dose ULT strategy
specific dose titration is left to provider
What is the target SU
< 6 mg/dl
What is the duration of ULT treatment
CONTINUE ULT indefinitely over stopping ULT is conditionally recommended
what are the different lifestyle that may increase uric acid or possibility of gout?
APOH
Alcohol intake 1.6 mg/dl higher than those who abstained
Purine rich food
Obesity (wt loss of 5 kg =1.1 mg/dl SU decrease; inc BMI >5% = 60% higher odds of flare
High fructose corn syrup 1 gm of fructose/kg increases SU by 1-2 mg/dl within 2 hours of ingestion
Vitamin C supplementation is insignificant
Is HTZ needs to be switch regardless of disease activity?
it is conditionally recommended for patients with gout
Is losartan prefered an an antihypertensive agent
It is conditionally recommended for patients with gout
is aspirin need to be stopped?
it is conditionally recommended against
adding or switching cholesterol-lowering agents to fenofibrate be done?
It is conditionally recommended against for patients with gout
Philppine CPG from this point: What is asymptomatic hyperuricemia
SU of > 7 mg/dl in male
SU of > 6 mg/dl in female
Initial steps in managing a patient with hyperuricemia
Correct modifiable risk factors/
Do not start ULT routinely
What should be done if a patient with acut gouty arthritis is alreading taking allopurinol?
do not change the dose of allopurinol
Recommended treatment of acute gout if there are no complications
colchine 0.5 mg tab TID to QID +/- NSAID/COX2
Lifestyle modifications on Water intake and Exercise
Water intake at least 2 l/day
Aerobic exercise at least 45 mins/day 4x a week
When (weeks) should allopurinol be started in patients with gout?
2 weeks after the pain and swelling subsided - Allopurinol at 100 mg/day and the dose should be titrated to achieve serum uric acid <6 mg/dl.
What are the indications for starting urate-lowering therapy (ULT)?
3Rs and T
Recurrent arthritis (at least 2 episodes),
Radiographic evidence of chronic gout
Recurrent uric acid nephrolithiases
(+) tophaceous deposits,
What is the maximum recommended dose of allopurinol?
The maximum dose of allopurinol is 300 mg/day.
What are the recommended non-pharmacologic measures for managing gout?
Dietary modification to promote weight loss, avoidance of alcohol, and low-impact exercises such as walking, biking, swimming, and ballroom dancing.
What is the role of colchicine in the management of gout?
Colchicine should be used at 0.5 mg/tab OD-BID to prevent gout flares when initiating allopurinol and should be maintained for 3-6 months from the last occurrence of gout flare and after the optimal SUA target is achieved.
What is the recommended treatment for acute gouty arthritis if there are contraindications to colchicine, NSAIDs, or COX-2 inhibitors?
A: Start Prednisone 30 mg single dose on day 1, reduce dose by 5 mg daily, and discontinue by day 7. Intravenous or intramuscular steroids are also options.
What should be done if arthritis is not resolving by day 7 of treatment for acute gouty arthritis?
Review adherence to medications, recheck if precipitants have been adequately treated, and refer to a rheumatologist.
What are the key recommendations for the management of asymptomatic hyperuricemia?
A: Asymptomatic hyperuricemia should not be routinely treated with allopurinol. Address well-known associated risk factors such as dyslipidemia, obesity, metabolic syndrome, psoriasis, malignancies, and congestive heart failure.
