Treatment of Gout Exam 2

Question 1

Nondrug for acute gouty arthritis

Answer 1

• Topical ice
• Rest inflamed joint
• Diet: 8-16 cups water/d, no alcohol, meat <4-6 oz/d; get protein from low fat dairy, tofu, eggs, nut butters

Question 2

Drug treatment overview for acute gouty arthritis

Answer 2

• Colchicine
• NSAIDs
• Corticosteroids
• IL-1 antagonist

Question 3

Treatment goal for acute gouty arthritis

Answer 3

relieve pain and inflammation (NOT decrease uric acid)

Question 4

Drug treatment for acute gouty arthritis: Colchicine

Answer 4

• At first sign of flare – two 0.6 mg doses, then 0.6 mg after 1 h
• Best response if first dose given within 12 h of onset of attack, not recommended if over 36 h since onset

Question 5

Drug treatment for acute gouty arthritis: NSAIDs

Answer 5

• very effective, may take 24 h for benefits
• Indomethacin, naproxen, sulindac FDA approved for acute gouty arthritis
• Salicylates should not be used; low doses inhibit urate secretion into renal tubules, high doses also inhibit reabsorption

Question 6

Drug treatment for acute gouty arthritis: Corticosteroids

Answer 6

• May be combined with colchicine to prevent rebound flares of gout as steroid is discontinued
• Oral prednisone, ACTH, IA injections

Question 7

Drug treatment for acute gouty arthritis: IL-1 antagonist

Answer 7

• b/c IL-1beta involved in urate crystal-induced inflammation
• anakinra (Kineret), rilonacept (Arcalyst), & canakinumab (Ilaris)?

Question 8

Colchicine MOA

Answer 8

inhibits neutrophil function & inflammatory response to urate crystals; persists in neutrophils as long as 10 d after single dose

Question 9

Colchicine choice in therapy

Answer 9

• Favorable for acute attacks (Pain relief in 24-48 h)

- also useful for chronic therapy

Question 10

IL-1 antagonist MOA

Answer 10

Reduce urate crystal-induced inflammation

Question 11

Allopurinol MOA

Answer 11

Xanthine Oxidase Inhibitor; purine analog

Question 12

Allopurinol choice in therapy

Answer 12

Prophylactic; urate lowering; treat to target uric acid

Question 13

Febuxostat MOA

Answer 13

Selective Xanthine Oxidase Inhibitor; non-purine

Question 14

Febuxostat choice in therapy

Answer 14

Prophylactic; urate lowering; use in patients with allopurinol hypersensitivity, intolerance, or treatment failure

Question 15

Uricosurics MOA

Answer 15

Inhibit reabsorption of urate by renal tubules

Question 16

Uricosurics choice in therapy

Answer 16

Prophylactic; urate lowering; preferred for underexcreters

Question 17

Lesinurad (Zurampic) MOA

Answer 17

Selective inhibitor of uric acid reabsorption; inhibits uric acid transporter URAT 1 & organic anion transporter OAT 4

Question 18

Lesinurad (Zurampic) choice in therapy

Answer 18

Prophylactic; urate lowering; Dose with xanthine oxidase inhibitor; combination product: Duzallo

Question 19

Fenofibrate MOA

Answer 19

reduces renal tubular reabsorption of uric acid

Question 20

Uricases (urate oxidases) MOA

Answer 20

Convert uric acid to allantoin (more soluble)

Question 21

Pegloticase MOA

Answer 21

PEGylated uricase enzyme

Question 22

Pegloticase choice in therapy

Answer 22

Prophylactic; urate lowering; hyperuricemia associated with refractory chronic gout or if intolerant to oral options

Question 23

Rasburicase (Elitek) choice in therapy

Answer 23

Prophylactic; urate lowering; hyperuricemia-associated with malignancy (tumor lysis syndrome)

Question 24

drugs that can induce hyperuricemia

Answer 24

• Diuretics
• Cyclosporine
• Salicylates (low dose)
• Other: pyrazinamide, ethambutol, nicotinic acid, levodopa, cytotoxic drugs, didanosine (ddI), topiramate

Question 25

Describe how presence of nephrolithiasis affects drug choice for hyperuricemia

Answer 25

* Uricosurics should not be used for patients with history of kidney stones * Allopurinol is the drug of choice for hyperuricemia with kidney stones * Do not give probenecid, fenofibrate, or losartan if pt has history of nephrolithiasis

Question 26

Describe the treatment of urate nephrolithiasis

Answer 26

* Maintain urine volume 2-3 L/d * Alkalinize urine to pH 6-6.5: Na bicarbonate, Shohl’s solution, Acetazolamide * Avoid high purine foods * Limit protein to <=90 g/d * Xanthine oxidase inhibitor (NOT uricosuric)

Question 27

How do you alkalinize the urine?

Answer 27

– Na bicarbonate – Shohl’s solution – Acetazolamide

Question 28

What are the Uricosurics?

Answer 28

* Probenecid * Lesinurad (Zurampic) * Lesinurad/allopurinol combination product (Duzallo) * Losartan * Fenofibrate * Atorvastatin & simvastatin

Question 29

What are the Uricases?

Answer 29

* Pegloticase (Krystexxa) | * Rasburicase (Elitek)

Question 30

Uricosurics MOA

Answer 30

inhibit reabsorption of urate by renal tubules

Question 31

Uricase MOA

Answer 31

Convert uric acid to allantoin (more soluble)