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Fall 2024 > Therapeutics Exam 4 Gout > Flashcards

Therapeutics Exam 4 Gout Flashcards

1
Q

What is gout?

A

An inflammatory process in response to crystallization of monosodium urate (MSU) in articular and non-articular tissues

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2
Q

What uric acid level signals hyperuricemia?

A

> 6.8 mg/dL

*and symptomatic

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3
Q

What is uric acid?

A

The main end product in purine degradation

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4
Q

What is allantoin?

A

Soluble byproduct from uric acid breakdown

-more soluble form of uric acid

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5
Q

What are the 3 main medications that can increase uric acid levels?

A

Diuretics (thiazides or any)

Cytotoxic drugs (chemo, methotrexate)

Salicylates

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6
Q

What is the presentation of acute gouty arthritis?

A

Podagra- (first metatarsal joint on foot involved)

Uric acid can deposit elsewhere (fingers, wrists, cartilage, tendons, kidneys)

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7
Q

WBC at what level could signify infection?

A

> 11,000

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8
Q

What are the complications of acute gouty arthritis?

A

Tophi (deposits of monosodium urate, form nodules)

Nephrolithiasis (kidney stones)

Gouty nephropathy (kidney disease)

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9
Q

What is the only way to get a definitive gout diagnosis?

A

Synovial fluid aspiration

-not done much

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10
Q

What are the 3 steps in gout treatment?

A

-Treat pain and inflammation

-Urate-lowering therapy (ULT) to prevent recurrence

-Anti-inflammatory prophylaxis

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11
Q

What is a possible non-pharm therapy for acute gouty arthritis?

A

Apply ice to the affected area

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12
Q

What are the 3 options for pharmacologic therapy for acute gout treatment?

A

NSAIDs

Corticosteroids

Colchicine

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13
Q

What are the NSAIDs that can be used in gout treatment?

A

Indomethacin

Naproxen

Ibuprofen (not approved but commonly used)

Sulindac

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14
Q

What is the key to NSAID use in gout?

A

Early initiation

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15
Q

What corticosteroids are used in gout treatment?

A

PO:
-Methylprednisolone
-Prednisone

IM:
-Triamcinolone
-Methylprednisolone

Intra-articular:
-Triamcinolone

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16
Q

If using an IM or IA corticosteroid, what needs to happen?

A

Follow up with subsequent anti-inflammatory agent (NSAID or po Corticosteroid)

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17
Q

What are the important considerations with corticosteroid treatment?

A

Need to taper doses

Limit treatment duration

Increased risk of GI bleed and peptic ulcer disease

Monitor diabetes for increased BG

Avoid intra-articular injections if infection is suspected

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18
Q

What is the MOA of colchicine?

A

Disrupts cytoskeletal functions
-inhibits B-tubulin polymerization into microtubules
-this prevents migration of neutrophils to sites of inflammation that cause gout symptoms

19
Q

Colchicine must be administered within how many hours of an acute gout attack?

A

24 hours

-because otherwise the neutrophils have already reached the site of the gout

20
Q

What is the dosing of colchicine?

A

Day 1: 1.2 mg po once, then 0.6mg one hour later

Day 2+: 0.6 mg BID until attack resolves

21
Q

How do we adjust colchicine dosing for renal impairment?

A

CrCl >/=30: No adjustment

CrCl < 30: 1.2 mg at onset, then 0.6 mg 1 hour later
*0.6 mg dose is only given once!!!
Only repeat every 2 weeks

Dialysis: A single 0.6 mg dose, only repeat every 2 weeks

22
Q

What two agents should we try to avoid combining?

A

NSAIDs
Corticosteroids

23
Q

What are the abortive gout agents?

A

NSAIDs
Colchicine

-patients can use the “pill in pocket” method

24
Q

Who is not a candidate for Urate Lowering Therapy (ULT)?

A

Asymptomatic hyperuricemia with no prior gout flares or tophi

First gout attack without risk factors

25
Q

When should urate lowering therapy be administered?

A

Recommended to wait 2 weeks after acute attack

-can be initiated during an acute attack though

26
Q

How long are patients on urate lowering therapy?

A

Indefinitely

27
Q

What are the 3 types of urate lowering therapy?

A

1st: Xanthine Oxidase Inhibitors

2nd: Uricosurics

3rd: Uricase Agents

28
Q

What is the moa of Xanthine Oxidase Inhibitors?

A

Reduces uric acid by:
-impairing the ability of xanthine oxidase to convert hypoxanthine to xanthine (and therefore to uric acid)

29
Q

What are the Xanthine Oxidase Inhibitors?

A

Allopurinol

Febuxostat

30
Q

What is the dosing of allopurinol?

A

Initial: 100mg po daily

*Titrate: Every 2-4 weeks in </= 100mg increments prn to achieve uric acid <6

31
Q

How do we adjust allopurinol dosing in renal impairment?

A

eGFR</= 60: Initial dose is 50mg daily

32
Q

What is a concern with allopurinol use?

A

Allopurinol Hypersensitivity Syndrome

-Stevens-Johnson Syndrome
-Toxic Epidermal Necrolysis

Watch for HLA-B5801 allele

33
Q

When is Febuxostat used?

A

When patients cannot tolerate allopurinol

34
Q

What is the MOA of Uricosurics?

A

Increase renal clearance of uric acid by inhibiting reabsorption

35
Q

What are the uricosuric drugs?

A

*Probenecid

Lesinurad (NOT FDA APPROVED)

36
Q

When is Probenecid contraindicated?

A

History of urolithiasis (kidney stones)

37
Q

What is the MOA of uricase agents?

A

Recombinant form of urate-oxidase enzyme

-Converts uric acid to more soluble metabolite allantoin

38
Q

What is the only uricase agent?

A

Pegloticase

39
Q

When is Pegloticase used?

A

SEVERE gout and hyperuricemia

(>/=3 flared in 18 months, >/= 1 tophi, joint damage from gout)

*Note that this is an IV infusion

40
Q

What is a concern with Pegloticase use?

A

Anaphylaxis
Infusion reactions

41
Q

What other medications can be used for gout treatment?

A

Fenofibrate
-increases hypoxanthine and xanthine clearance

Losartan
-Preferred agent for gout and HTN

42
Q

When do we use gout prophylaxis?

A

When initiating Urate Lowering Therapy

43
Q

How long do we use gout attack prophylaxis?

A

First 3-6 months of ULT initiation

44
Q

What agents do we use for prophylaxis?

A

NSAIDs -lowest effective dose

Prednisone (</= 10 mg/day)

Colchicine (0.6mg daily or BID)

Fall 2024 (16 decks)

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