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Therapy: year 3 > Gout > Flashcards

Gout Flashcards

1
Q

Is gout an inflammatory or noninflammatory disorder?

A

inflammatory

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2
Q

what is the main cause of gout?

A

hyperurecimeia

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3
Q

what concentrations of uric acid are indicative of gout in men and females?

A

416 mew mol for men
357 mew mol for women

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4
Q

does elevated uric acid levels always lead to gout?

A

we can have asymptomatic gout!

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5
Q

what are some risk factors for gout?

A
  • men (3 times as common)
  • 40 (for men) and 60 (for females)
  • sedentary lifestyle, obesity
  • food high in purines (alchol)
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6
Q

what stage of purine degradation is uric acid?

A

the final stage

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7
Q

talk about limits of solubility

A

normal serum uric acid level are already at the limit of solubility so it takes very little to shift this balance

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8
Q

hyperurcemia is the cause of what?

A

over production or underextrection of uric acid (under excration is most commonly the cause)

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9
Q

discuss what can lead to over production?

A
  • cell death (cells have a lot of uric acid in them) - meds used to treat blood cancer cause cell death
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10
Q

can diet cause over production?

A

rarely

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11
Q

what are the two types of drugs that affect uric acid production?

A
  • xanthine oxidase inhibitors (allopurinol, and febuxostat)
  • renal reabsorption
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12
Q

discuss what can lead to under execration?

A
  • dehydration - we retain Na and therefore we also retain uric acid
  • drugs can affect it ( thiazide diruretics)
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13
Q

how much uric acod is excreted through the renal system?

A

2/3

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14
Q

do we know why underexcretion of gout patients ahppnes?

A

not always - 90% unknown but as mentioned

dehydration and drugs can affect the excretion

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15
Q

what are the 4 clinical spectrums of the disease?

A
  1. asymtomatic
  2. gouty flare
  3. prophylaxis of flares
  4. chronic gouty arthitis (crystals formed in joints)
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16
Q

what is the treament for asymtopmatic gout?

A

non-phram

  • no meds
  • lifestyle changes (exercise, food less high in purines)
  • identify drugs that may be leading to disccus and discuss changing them
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17
Q

what is the treament for a gout flare? what drugs can we use?

A
  • treat within 24 hours
  • NSAIDS
  • Colchinie
  • Oral steroids
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18
Q

what two drugs for treament of flares can never be combine?

A

NSAIDS and Oral steroids ( could cause toxicity)

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19
Q

monotherapy or two agents? also what are the options

A

try one agent but we can add another if needed

NSAID + colchinie
Colchine and oral steroid
IA steroid or NSAIS + colchine

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20
Q

what are the signs of a gout flare?

A

excruatiating pain, inflammation, sweeling

  • fever elevated wbc
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21
Q

is it monarticular or biartiuclar?

A

monoarticular usualy

22
Q

where does it often happen?

A

big toes, ankle, heel, knees, wrist, fingers, elbow (rarely)

23
Q

distinguish between a presumptive diagnosis and a definitive diagnosis

A

presumptive - lab work (high uric acid), pain, inflammation of the big toe

definitive - take sample of synovial fluid and chvcek for presence of cystrals

24
Q

when is combo therpay indicated?

A

severe gout >7 on pain scale

25
Q

NSAID used? monitoring ? dosing?

A

indomethacin (has CNS SE) , if pain doesn’t get better in 7 days see a doc , dosing (loading dose so big amount to start then titrate down)

26
Q

When should we start colchine?

A

within 36 hours - can give patient a PRN supple if they ahve repesetd gout attacks

27
Q

What special consideration should we take when dosing elderly and those who are renally impaired with colchine?

A

reduce dose

28
Q

what are some side effects common and rare of colchine?

A

common (in high doses) - abdominal pain and cramps, diarrhea, nausea and vomiting

Rare: neuropathy, myopathy, bone marrow suppression (a worry for those with renal insifficney)

29
Q

Drug interactions for colchicine

A
  • Statins level may increase so monitor for myotoxicity (muscle weakness, pain)
  • If taking knonw CYP 3A4 inhibotrs, decrease dose and moniot for fever, leukopenia, GI symptoms) - these could be clarithyrmycin, - azonles
30
Q

what is an important counseling point for colchine

A

avoid graphfruit

31
Q

Oral or IA corticosteroid use?

A

Both

32
Q

when is oral vs IA corticosteroid use indicated?

A

oral when more than two joints are affected

IA when 1-2 joints are involved and they must be big joints

33
Q

what is the dosing for oral corticosteroids like?

A

prednisone - large dose to start off for 5 to 10 days, if used for less then 10- days no need for titrating down before discontinuing BUT beware that rebound attacks may occur

34
Q

what are the two goal styles for prophylaxis therapy?

A

treat to target - less then 300 mew mol SUA, 360 for those with severe gout

treat to manage symptoms

35
Q

when is uric lowering therapy indicated?

A

-when more then 2 gout attacks per year
- presence of uric acid stones
- presence of calcifcation tophi, tophus
- reduced kidney fucntion less then 90 mL/min

36
Q

what does ULt therpay look like?

A
  1. start ULt therpay with allopurinol or febuxostat
  2. start low dose NSAID or colchine for 3-6 months after initiation ULT
37
Q

does ULT risk or decrease risk for gout attacks

A

can increease thus we need NSAID and colchine for first 3-6 months

38
Q

what is first line for ULT

A

allopurinol

39
Q

what risk factors should we be cautious of in allopurinol use?

A
  • elderly
  • hepatic impariment
  • renal impairment
  • CKD
40
Q

common side effects of Allopurinol?

A

Gi upset
can preciptate gout attack

41
Q

serious side effects of allopuirnol

A

IF YOU DEVELOP A RASH OR ITCH STOP DRUG USE AND SEE HCP

  • Steven johnson syndrom
  • ten
  • DRESS
42
Q

how should we dose allopurinol? and moniotr

A

start low and go slow - can increase every 2-4 weeks

chcek lab values for SUA and renal function

43
Q

what dose of allopurinol is usually needed to be effective?

A

300 mg/day

44
Q

when is febuxostat/uloric indicated?

A

when we fail allopurinal or there is severe renal impriament

45
Q

what are some drug interaction with allopurinol to note?

A

Azathipine and mercaptopurine - thiopruity toxicity - bone marrow suppression

46
Q

Why is febuxostat indicated for renal insuffeincy?

A

very little is excreted renally

47
Q

what has more flares during initiation, allopurinol or febuxostat?

A

febuxostat

48
Q

drug interactions with febuxostat

A

azathioprine and mercaptopurine (CI)

Theophyline?

49
Q

AE of febuxostat

A
  • abnorlmities in LFTS
  • Gi upset
  • may increase cv risk
50
Q

what is the moniotring for both phrophylauxs agents

A

2-4 weeks chcek SUA and increase dose, chcke renal function as well

3-6 once target reached

LFTS- if taking febuxostat

51
Q

if renally impaired (crcl less then 90ml/min) what do we do for acute and prophylaxis therpay?

A

acute
-colchicine or steroids
- avoid NSAIDs

Prophylactic
- febuxostat
- allopurinol - with a dose adjustment

52
Q

if CV comordbidities what do we do for acute and prophylaxis therapy?

A

acute:
- colchicine
- avoid NSAIDS and steroids for those in heart fialure

Prophylactic
- allopurinol
- febuxostat avoid

Therapy: year 3 (14 decks)

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