Therapeutics - Gout Flashcards
true or false
not every patient with gout has hyperuricemia, and not every patient with hyperuricemia has gout
true - not known why this is the case
gout itself is not life threatening, but when does it become a concern?
can cause kidney damage which can be fatal
nephrolithiasis (kidney stones)
gouty nephropathy
what is pseudogout
the crystals are different and the attacks are longer
in gout, they are monosodium urate crystals
in pseudogout, they are calcium pyrophosphate dihydrate crystals
true or false
someone with gout vs pseudogout gets very different treatment
false - similar treatment
true or false
uric acid has NO biologic function
TRUE
how is uric acid excreted?
it is the end product of what?
renally
purine metabolism
what is NORMAL UA serum concentration
2-7mg/dL
around what % of patients with hyperuricemia are underexcretors vs overproducers?
around 90% are under excretors and around 10% are overproducers
name some ways someone can be an overproducer of uric acid
if they have a high cell turnover due to numerous diseases like psoriasis, chemotherapy (tumor lysis), lymphomas, genetics related to purine metabolism, myeloproliferative disorders
name some ways someone can be an underexcretor of gout
name 3 drugs that can cause this
genetics, chronic kidney disease, hypertension
thiazides/loop diuretics, aspirin (not really a problem. low dose aspirin not an issue), and cyclosporine A
someone’s diet and alcohol use can make them a _______ of uric acid
overproducer
TRUE OR FALSE
gout is the most common inflammatory arthritis
true
osteoarthritis is the most common DEGENERATIVE arthritis
what is average onset age for gout
58 – late 50s
is gout more likely in men or women
7-9 times more likely in men
true or false
the risk for gout increases with age
true
true or false
obesity is a risk factor for gout
true
name some risk factors for gout
HTN
obesity
diabetes/metabolic syndrome
CKD
diet rich in meat/seafood
alc and drugs
name 2 drugs used for TB treatment that can induce hyperuricemia
pyrazinamide and ethambutol
name 2 uricosuric drugs
losartan and fenofibrate
so, for HTN, use losartan over HCTZ
true or false
low dose aspirin needs to be discontinued if patient is experiencing hyperuricemia
FALSE - not really an issue
a symptom of gout is erythema of the joint
around when does it reach its peak intensity
within 6-12 hours
name the joint typically affected by acute gout (50% of cases)
the monoarticular joint of the big toe (connects toe to foot)
aside from big toe, name 2 other joints typically affected by gout
knee and ankle, sometimes the hands
the onset of gout pain is typically at what time of day and why?
at night
water is resorbed into the body at night and any urate will deposit
acute gout is EPISODIC
without treatment, how long does it typically last
3-14 days
are fever and flu-like symptoms possible in an acute gout attack
it’s rare, but possible
long term consequences of gout if acute attacks continually occur
joint destruction, tophi formation ,and nephrolithiasis (kidney stones)
clinical presentation of acute gout
red, hot, swollen joint, typically of big toe
recurrent attacks may be polyarticular (mult joints) and last longer than the initial attack
how can diagnosis of gout be confirmed? is this ideal?
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
what are tophi and when do they typically occur
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
name some factors that can EXACERBATE an acute gouty attack
exercise (for ppl that dont do so regularly)
alcohol
trauma
drugs
infection
explain geriatric gout
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
how to identify tophi by looking at picture
a white nodule
true or false, in pseudogout, uric acid is not the cause
true
what ages are typically affected by gout in each gender
men - greater than 35
women of postmenopausal age
true or false
the prevalence of gout between men and women is pretty evenly distributed
FALSE
more common in men
PSEUDOGOUT is pretty even
typical affected joint of gout vs pseudogout
gout - first MTP joint (metatarsophalangeal)
pseudo - the knee
SHORT TERM goals of gout therapy
what about long term
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
long term goal of gout therapy is to decerase uric acid levels below….
6mg/dL
(norm is 2-7)
name 3 drugs only used if patient is an UNDEREXCRETOR
probenecid (uricosuric)
if they have the conditions - losartan/fenofibrate
name 7 drugs that are used as general treatment in gout, whether the person is an overproducer or an underexcretor
NSAIDS
colchicine
corticosteroids
allopurinol
febuxostat
pegloticase
lesinurad (WITH XO INHIBITOR)
acute gouty arthritis attack:
should be treated with drugs preferably within how long of the attack onset?
name a NON pharmacologic therapy
within 24 hours is preferred - gives the best benefit
can ice the affected joint
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
still continue it
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
1st line = NSAIDS
2nd = colchicine
3rd = systemic corticosteroids
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?
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
NSAIDS and colchicine both cant be used
what to do if:
-greater than 2 joints involved
-no greater than 2 joints involved
if greater than 2, use systemic corticosteroids
if not, use IA corticosteroids
explain when NSAID therapy should NOT be used in gout patients
renal issues
peptic ulcer disease
on anticoagulants (risk of bleeding)
hypertension (if not well controlled)
congestive heart failure
history GI bleeds
if the acute gout symptoms have not resolved after proper treatment, what should be done
reevaluate the diagnosis and if they were adherent to the regiman
true or false
NSAIDS are the drug of choice for acute gout attacks and can be used for repeat attacks
true
how do NSAIDS work to treat gout?
do they affect the disease itself?
they reduce joint pain and swelling
do NOT alter the course of the disease - do not affect UA levels
when using NSAIDS for acute gout attack, when should the therapy be discontinued?
2-3 days after the symptoms have resolved
which NSAID should be avoided in older adults for acute gout and why
INDOMETHACIN
has more CNS and GI side effects
in GENERAL, the duration of NSAID therapy is what range?
5-7 days
(stop 2-3 days after symptoms resolve)
what should be added to NSAID therapy in some scenarios?
a PPI if patient has a history of GI issues
GI upset is a side effect of NSAIDS what can be done to prevent
take WITH FOOD
which NSAID is actually used off label for acute gout attack
celecoxib
true or false
any NSAID can be used for acute gout attack
true - just avoid indomethacin in older patients
most common are naproxen, celecoxib, and indomethacin
how many x a day are naproxen and celecoxib given? what about indomethacine
naproxen and celecoxib = BID
indomethacin = Q8 hours
name 3 systems negatively affected by NSAIDS and the system only affected by INDOMETHACIN
GI, renal, CV
CNS = indomethacin
why are NSAIDS not used in CHF patients
can exacerbate it - causes sodium and water retention
that’s why also not given to someone with uncontrolled HTN
caution should be used in giving NSAIDS to pts with creatinine clearance less than…
60mL/min
true or false
if you don’t have gout, colchicine will still work
FALSE - will not
this is why it can be used to help diagnose gout
colchicine is useful if the pt has a contraindication to….
NSAIDS
how long to respond after given colchicine? when are the best effects observed?
response within hours
best if given within 24 hrs of symptom onset
FDA approved colchicine dosing for acute gout attack
what is the pt was already on it for prevention
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
off label dosing for acute gout attach
0.6mg TID on day of flare and then 0.6mg QD or BID until resolution
when giving colchicine for acute gout attack, cannot give another course of it for how long?
3 days
adverse events of colchicine (not severe)
NVD
abdominal pain
increased risk myopathy if given with statin
peripheral neuropathy
TRUE OR FALSE
an overdose of colchicine can be life threatening
true
name some SEVERE colchicine toxicity
blood cytopenia
rhabdomyolisis
peropheral nephropathy
liver failure
cutaneous eruption
IF USED LONG TERM - decreased B12 absorption – need supplements to prevent macrocytic anemia
