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Intro to D&D Final > Therapeutics - Gout part 2 > Flashcards

Therapeutics - Gout part 2 Flashcards

1
Q

symptoms of colchicine toxicity begin within…

A

2-5 hours

may lead to organ failure within 24-72hrs

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2
Q

doses of colchicine as small as___ have been fatal

A

8mg

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3
Q

name some treatment for colchicine toxicity

A

stomach pumping (gastric lavage)
activated charcoal

is NOT dialyzable

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4
Q

dose of colchicine as PROPHYLAXIS

A

0.6mg QD or BID for 3-6 months after starting UA lowering therapy to prevent attacks from starting the XO inhib

if they feel attack - start using flare doses (1.2mg stat and 0.6mg 1 hour later)

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5
Q

in what patients is colchicine used as prophylaxis

A

pts who have recurrent attacks and NORMAL URIC ACID (allopurinol wont help)

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6
Q

corticosteroids are ____ line for gout

A

3rd line

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7
Q

what steroid is typically given IA and which 2 typically IM

A

IA - trimcinolone

IM - triamcinolone or methylprednisolone

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8
Q

approx how long is oral corticosteroid therapy?

what is dose

important considerations

A

around 10-14 days

0.5mg/kg/day of prednisone for 5-10 days OR 2-5 days and then taper off for 7-10 days

DONT WANT REBOUND FLARES - taper off

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9
Q

corticosteroids should be used in caution in pts with which 3 health conditions

A

HTN
CHF
diabetes

can cause hyperglycemia and sodium and water retnetion

however, only given short term so not really the biggest concert

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10
Q

if all 3 agents (NSAIDS, colchicine, CS) are ineffective/cant be used, what can be used?

(NAME 2)

A

IL-1 inhibitors

anakinra and canakinumab

considered off label

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11
Q

give 2 scenarios in which urate lowering therapy (prevention) should NOT BE USED

A

-if UA is only mildly elevated (like around 8)

-if the first episode was mild and responsed well to treatment

watch and see first if UA levels go down or if they have more attacks 1st

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12
Q

4 scenarios in which UA lowering therapy SHOULD be started

A

-have frequent attcks (2 or more in a year) - discuss with pt

-have uric acid kidney stones - CKD stage greater than or equal to 2

-evidence of tophi for greater than or equal to a year (sign of more longstanding disease)

-have chronic joint damage from the gout – dont want further disability

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13
Q

definition of hyperuricemia

A

serum UA is GREATER THAN 7mg/dL

as mentioned - if it’s 8 - dont start urate lowering therapy yet

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14
Q

if a pt has hyperuricemia but no symptoms of flares or tophi, should it be treated with urate lowering therapy?

A

NOO

MIGHT consider if it’s very severely elevated

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15
Q

scenarios in which we may consider urate lowering therapy in someone that just had 1 gout attack

A

the UA level greater than 9

have mod-severe CKD

-kidney stones (urolithiasis)

pts on chemo or radiotherapy (tumor lysis syndrome)

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16
Q

if a pt is on chemo and at risk of tumor lysis syndrome, what may they be treated with

A

allopurinol or rasburicase (specific for hyperuricemia with chemo)

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17
Q

name the 4 classes of drugs approved for urate lowering therapy

A

XO inhibitors

uricosurices

uricase agents

URAT 1 (uric acid transporter 1) inhibitor

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18
Q

name 2 XOIS

A

allopurinol and febuxostat

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19
Q

name a uricosuric agent

A

probenecid

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20
Q

name a uricase agent

A

pegloticase

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21
Q

name URAT 1 inhibitor

A

lesinurad

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22
Q

ULT (urate lowering therapy) drugs are given with _____ for _______ to prevent _______

A

anti-inflammatories for 3-6 months to prevent gout caused by initiating ULT

ex: colchicine, NSAIDS, prednisone

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23
Q

target UA when using ULT

A

less than 6mg/dL

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24
Q

true or false

ULT treatment is stopped after 3-6 months of improvement

A

FALSE

it’s continued forever

25
Q

1st line ULT

A

allopurinol

26
Q

true or false

XOIs are useful for BOTH under excreters and over prodicuers

A

TRUE

27
Q

can allopurinol be used in CKD?

A

yes - just need to lower the dosing

28
Q

regular dosing of allopurinol

A

100mg/day

increase every 4 weeks to 200-300mg a day

some pts may need 600-800 a day

29
Q

monitoring parameters for allopurinol

A

serum UA (obviously)
CBC
hepatic and renal function

30
Q

why is allopurinol started at low doses of 100mg/day

A

reduce hypersensitivty reaction risk and risk of causing an acute gout attack

31
Q

what is AHS

A

allopurinol hypersensitivity reaction

rare but severe - causes SJS, TEN, rash, eosinophilia

this is why doses are started LOW

32
Q

which ppl are particularly at risk for AHS due to HLA-B*5801 allele

A

koreans, han chinese, thai, african americans

33
Q

BLACK BOX WARNING FEBUXOSTAT

A

increased risk of CV related deaths like MI, stroke compared to allopurinol

thus, allopurinol should only be used in pts not responding to max dose of allopurinol, or contraindicated

34
Q

febuxostat should be avoided in patients with severe ____ impairment

A

hepatic

35
Q

dosage febuxostat

A

40mg QD

increase to 80mg after 2 weeks if UA not below 6 – has easier trituation than allopurinol

36
Q

when would pegloticase be used

A

as last resort in pts with advanced gout and uncontrollable by the other ULTs

reduces uric acid levels and fixes tophi

37
Q

pegloticase is contraindicated in what patients

A

with G6PDH deficiency

38
Q

true or false

when using pegloticase, it takes a long time to see effects

A

FALSE - improves rapidly, but also very expensive

39
Q

how is pegloticase given

A

via infusion

40
Q

ppl starting pegloticase should be pretreated with what

A

antihistamines and corticosteroids to prevent BBW of infusion reaction

also, give colchicine or NSAID for 1 week before and 6 months after treatment

41
Q

role in therapy for lesinurad

A

used only in COMBINATION with an XO inhibitor in pts who failed on XO inhib alone

42
Q

black box warning lesinurad

A

risk of renal failure

risk decreases when given with XOI (that’s why we do it)

43
Q

when is lesinurad contraindicated

A

pts with bad renal function

44
Q

dosage lesinuard

A

200mg QD with XOI

45
Q

what is duzallo

A

lesinurad + allopurinol

46
Q

probenecid is a ____ agent

how long to see benefit? when can it NOT be started and why

A

uricosuric

6-12 months to see effect

NOT started during an acute gout flare bc can cause more kidney stones

47
Q

imp counseling pt for pts on probenecid

A

lot of fluids

48
Q

probenecid is contraindicated in which pts

A

with history kidney stones or mod-severe CKD

49
Q

probenecid is used as add-on therapy in what pts?

A

pts not reaching goal with just XOI treatment

50
Q

what are fenofibrate and losartan

A

uricosuric agents

51
Q

monitoring on probenecid

A

serum UA (obvious)
CBC
RENAL FUNCTION

52
Q

what drugs decrease effects of probenecid

A

salicylates

53
Q

outline for treating refractory gout

A
  1. start with XOI as monotherapy. if serum UA target not achieved….
  2. ADD URICOSURIC (probenecid). if not achieved still and disease activity is continued….
  3. add pegloticase or lesinurad (RARE)1
54
Q

1st and 2nd line for acute gout prophylaxis when starting ULT

A

1st line - colchicine 0.6mg QD or BID OR low dose NSAID (naproxen 250mg BID) BUT chronic NSAID use not rec. in older pts)

2nd line - low dose prednisone (less than 10mg a day)

continue these therapies for 3-6 months AFTERRRRRRR target uric acid levels have been achieved with ULT

55
Q

some nonpharm gout treatment

A

lose weight
proper diet
regular exercse

limit red meats, organ meats, high fructose corn syrup, alcohol, fish, stop smoking

can also ice the joint for pain relief!

56
Q

true or false

during gouty attacks, alcohol consumption should be totally avoided

A

true

57
Q

alcohol intake should be limited to prevent gout flares

explain what this means for men vs women

A

men - no more than 2 drinks a day

women - no more than 1

58
Q
A

Intro to D&D Final (21 decks)

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