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Intro to D&D Final > Therapeutics - Gout > Flashcards

Therapeutics - Gout Flashcards

1
Q

true or false

not every patient with gout has hyperuricemia, and not every patient with hyperuricemia has gout

A

true - not known why this is the case

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2
Q

gout itself is not life threatening, but when does it become a concern?

A

can cause kidney damage which can be fatal

nephrolithiasis (kidney stones)
gouty nephropathy

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3
Q

what is pseudogout

A

the crystals are different and the attacks are longer

in gout, they are monosodium urate crystals
in pseudogout, they are calcium pyrophosphate dihydrate crystals

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4
Q

true or false

someone with gout vs pseudogout gets very different treatment

A

false - similar treatment

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5
Q

true or false

uric acid has NO biologic function

A

TRUE

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6
Q

how is uric acid excreted?
it is the end product of what?

A

renally

purine metabolism

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7
Q

what is NORMAL UA serum concentration

A

2-7mg/dL

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8
Q

around what % of patients with hyperuricemia are underexcretors vs overproducers?

A

around 90% are under excretors and around 10% are overproducers

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9
Q

name some ways someone can be an overproducer of uric acid

A

if they have a high cell turnover due to numerous diseases like psoriasis, chemotherapy (tumor lysis), lymphomas, genetics related to purine metabolism, myeloproliferative disorders

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10
Q

name some ways someone can be an underexcretor of gout

name 3 drugs that can cause this

A

genetics, chronic kidney disease, hypertension

thiazides/loop diuretics, aspirin (not really a problem. low dose aspirin not an issue), and cyclosporine A

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11
Q

someone’s diet and alcohol use can make them a _______ of uric acid

A

overproducer

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12
Q

TRUE OR FALSE

gout is the most common inflammatory arthritis

A

true

osteoarthritis is the most common DEGENERATIVE arthritis

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13
Q

what is average onset age for gout

A

58 – late 50s

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14
Q

is gout more likely in men or women

A

7-9 times more likely in men

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15
Q

true or false

the risk for gout increases with age

A

true

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16
Q

true or false

obesity is a risk factor for gout

A

true

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17
Q

name some risk factors for gout

A

HTN
obesity
diabetes/metabolic syndrome
CKD
diet rich in meat/seafood
alc and drugs

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18
Q

name 2 drugs used for TB treatment that can induce hyperuricemia

A

pyrazinamide and ethambutol

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19
Q

name 2 uricosuric drugs

A

losartan and fenofibrate

so, for HTN, use losartan over HCTZ

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20
Q

true or false

low dose aspirin needs to be discontinued if patient is experiencing hyperuricemia

A

FALSE - not really an issue

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21
Q

a symptom of gout is erythema of the joint

around when does it reach its peak intensity

A

within 6-12 hours

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22
Q

name the joint typically affected by acute gout (50% of cases)

A

the monoarticular joint of the big toe (connects toe to foot)

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23
Q

aside from big toe, name 2 other joints typically affected by gout

A

knee and ankle, sometimes the hands

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24
Q

the onset of gout pain is typically at what time of day and why?

A

at night

water is resorbed into the body at night and any urate will deposit

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25
Q

acute gout is EPISODIC
without treatment, how long does it typically last

A

3-14 days

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26
Q

are fever and flu-like symptoms possible in an acute gout attack

A

it’s rare, but possible

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27
Q

long term consequences of gout if acute attacks continually occur

A

joint destruction, tophi formation ,and nephrolithiasis (kidney stones)

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28
Q

clinical presentation of acute gout

A

red, hot, swollen joint, typically of big toe

recurrent attacks may be polyarticular (mult joints) and last longer than the initial attack

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29
Q

how can diagnosis of gout be confirmed? is this ideal?

A

by aspirating the joint fluid and seeing lot of WBC and monosodium urate crystals

NOT IDEAL - this would hurt like a B in a joint affected by gout. we can still treat gout without doing all this

30
Q

what are tophi and when do they typically occur

A

occur later in the disease

they are urate deposits in the soft tissue arounf the joint - may cause soft tissue damage and may ulcerate and get infected. they can ooze a white goo

31
Q

name some factors that can EXACERBATE an acute gouty attack

A

exercise (for ppl that dont do so regularly)
alcohol
trauma
drugs
infection

32
Q

explain geriatric gout

A

older, post-menopausal women more likely to get it than younger women

also, in geriatrics, more than 1 joint is typically involved and the small joints of fingers affected early in the disease

they also develop tophi sooner

33
Q

how to identify tophi by looking at picture

A

a white nodule

34
Q

true or false, in pseudogout, uric acid is not the cause

A

true

35
Q

what ages are typically affected by gout in each gender

A

men - greater than 35

women of postmenopausal age

36
Q

true or false

the prevalence of gout between men and women is pretty evenly distributed

A

FALSE

more common in men

PSEUDOGOUT is pretty even

37
Q

typical affected joint of gout vs pseudogout

A

gout - first MTP joint (metatarsophalangeal)

pseudo - the knee

38
Q

SHORT TERM goals of gout therapy

what about long term

A

stop the acute attack and relieve the pain and inflammation

long term - prevent recurrences, prevent complications of UA deposition (joint deformity and kidney issues) and get UA levels to less than 6 mg/dL

39
Q

long term goal of gout therapy is to decerase uric acid levels below….

A

6mg/dL

(norm is 2-7)

40
Q

name 3 drugs only used if patient is an UNDEREXCRETOR

A

probenecid (uricosuric)

if they have the conditions - losartan/fenofibrate

41
Q

name 7 drugs that are used as general treatment in gout, whether the person is an overproducer or an underexcretor

A

NSAIDS
colchicine
corticosteroids
allopurinol
febuxostat
pegloticase
lesinurad (WITH XO INHIBITOR)

42
Q

acute gouty arthritis attack:

should be treated with drugs preferably within how long of the attack onset?

name a NON pharmacologic therapy

A

within 24 hours is preferred - gives the best benefit

can ice the affected joint

43
Q

a patient is currently on urate lowering therapy and despite this, suffers from an acute gout attack.

should the urate therapy be stopped or continued

A

still continue it

44
Q

patient suffers an acute attack with mild-moderate pain with only 1 or a few SMALL JOINTS or 2-3 large joints affected

name the 3 MONOTHERAPY agents that can be used - 1st, 2nd, and 3rd line

A

1st line = NSAIDS

2nd = colchicine

3rd = systemic corticosteroids

45
Q

as mentioned, for an acute gout attack, first line is NSAIDS, then colchicine, then systemic steroids

what is the patient has inadequate response to this?
what is considered inadequate response?

A

less than 20% improvement in pain score within 24 hours, or 50% at over 24 hours

either switch to alternative monotherapy OR add something else as combination therapy

46
Q

NSAIDS and colchicine both cant be used

what to do if:

-greater than 2 joints involved
-no greater than 2 joints involved

A

if greater than 2, use systemic corticosteroids

if not, use IA corticosteroids

47
Q

explain when NSAID therapy should NOT be used in gout patients

A

renal issues
peptic ulcer disease
on anticoagulants (risk of bleeding)
hypertension (if not well controlled)
congestive heart failure
history GI bleeds

48
Q

if the acute gout symptoms have not resolved after proper treatment, what should be done

A

reevaluate the diagnosis and if they were adherent to the regiman

49
Q

true or false

NSAIDS are the drug of choice for acute gout attacks and can be used for repeat attacks

A

true

50
Q

how do NSAIDS work to treat gout?
do they affect the disease itself?

A

they reduce joint pain and swelling
do NOT alter the course of the disease - do not affect UA levels

51
Q

when using NSAIDS for acute gout attack, when should the therapy be discontinued?

A

2-3 days after the symptoms have resolved

52
Q

which NSAID should be avoided in older adults for acute gout and why

A

INDOMETHACIN

has more CNS and GI side effects

53
Q

in GENERAL, the duration of NSAID therapy is what range?

A

5-7 days

(stop 2-3 days after symptoms resolve)

54
Q

what should be added to NSAID therapy in some scenarios?

A

a PPI if patient has a history of GI issues

55
Q

GI upset is a side effect of NSAIDS what can be done to prevent

A

take WITH FOOD

56
Q

which NSAID is actually used off label for acute gout attack

A

celecoxib

57
Q

true or false

any NSAID can be used for acute gout attack

A

true - just avoid indomethacin in older patients

most common are naproxen, celecoxib, and indomethacin

58
Q

how many x a day are naproxen and celecoxib given? what about indomethacine

A

naproxen and celecoxib = BID
indomethacin = Q8 hours

59
Q

name 3 systems negatively affected by NSAIDS and the system only affected by INDOMETHACIN

A

GI, renal, CV

CNS = indomethacin

60
Q

why are NSAIDS not used in CHF patients

A

can exacerbate it - causes sodium and water retention

that’s why also not given to someone with uncontrolled HTN

61
Q

caution should be used in giving NSAIDS to pts with creatinine clearance less than…

A

60mL/min

62
Q

true or false

if you don’t have gout, colchicine will still work

A

FALSE - will not

this is why it can be used to help diagnose gout

63
Q

colchicine is useful if the pt has a contraindication to….

A

NSAIDS

64
Q

how long to respond after given colchicine? when are the best effects observed?

A

response within hours

best if given within 24 hrs of symptom onset

65
Q

FDA approved colchicine dosing for acute gout attack

what is the pt was already on it for prevention

A

1.2mg (2 tabs) STAT then 0.6mg in 1 hour (total is 1.8mg)

if pt was already on for prevention, wait 12 hours after taking attack dose ^^ and then resume the prophylactic dose of 0.6mg QD or BID

66
Q

off label dosing for acute gout attach

A

0.6mg TID on day of flare and then 0.6mg QD or BID until resolution

67
Q

when giving colchicine for acute gout attack, cannot give another course of it for how long?

A

3 days

68
Q

adverse events of colchicine (not severe)

A

NVD
abdominal pain
increased risk myopathy if given with statin
peripheral neuropathy

69
Q

TRUE OR FALSE

an overdose of colchicine can be life threatening

A

true

70
Q

name some SEVERE colchicine toxicity

A

blood cytopenia
rhabdomyolisis
peropheral nephropathy
liver failure
cutaneous eruption

IF USED LONG TERM - decreased B12 absorption – need supplements to prevent macrocytic anemia

71
Q
A

Intro to D&D Final (21 decks)

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