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Naplex > Gout > Flashcards

Gout Flashcards

1
Q

What is gout and its cause?

A
  • Gout is a type of arthritis caused by a buildup of uric acid (UA) crystals, primarily in the joints
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2
Q

How is UA produced?

A
  • UA is produced as an end-product of purine metabolism
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3
Q

T/F: Purines are present in many foods, and they make up one of the base pairs of DNA

A
  • True
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4
Q

When UA builds up in the blood, the patient can remain __ or the UA can __ in the joints, resulting in a __ gout attack

Fill in the blanks

A
  • Asymptomatic
  • Crystallize
  • Painful
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5
Q

What are the characteristics of a gout attack?

A
  • Sudden onset
  • Typically in one joint
  • Most often in metatarsophalangeal joint (MTP, the big toe)
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6
Q

What is used to identify UA crystals in the body?

A
  • A sample of synovial (joint) fluid
  • Evaluating UA level in the body
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7
Q

What are the risk factors for gout?

A
  • Male sex
  • Obesity
  • Excessive alcohol consumption
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8
Q

List drugs that increase UA

A
  • Aspirin, lower doses
  • Calcineurin inhibitors (tacrolimus and cyclosporin)
  • Diuretics (loops and thiazides)
  • Niacin
  • Pyrazinamide
  • Select chemotherapy (with tumor lysis syndrome)
  • Select pancratic enzyme products
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9
Q

T/F: Asymptomatic hyperuricemia is not treated with drugs

A
  • True
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10
Q

The drugs used for acute attacks target __ and __.

Fill in the blanks

A
  • Pain
  • Inflammation
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11
Q

Why prophylactic drugs are used?

A
  • Used to lower UA levels with a goal UA level of < 6 mg/dL
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12
Q

Which anti-inflammatory drugs are used to treat acute pain?

A
  • Colchicine
  • Steroids (including intra-articular injections)
  • NSAIDs (often with a high starting dose)
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13
Q

Once gout has struck, which medications are used to chronically treat to prevent future attacks?

A

Xanthine oxidase inhibitor (XOI):
* Allopurinol (preferred)

  • Febuxostat
  • An acute gout flare can occur when an XOI is started, so give initially with colchicine or an NSAID

If XOI didn’t work well and UA remains >6 mg/dL:
* Add on probenecid or lesinurad to daily XOI

  • Replace the XOI with IV pegloticase (Krystexxa)
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14
Q

How do you initially treat acute gout attack?

A
  • It should be treated with a single drug, either an NSAID, a systemic steroid or colchicine
  • If severe, combination treatment should be initiated. Thiis included colchicine with either an NSAID or an oral steroid
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15
Q

What can be helpful if the gout attack is localized to one or two joints?

A
  • An intra-articular steroid injection which is injected into joint/s
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15
Q
A
16
Q

T/F: The ULT treatment should be continued if an acute attack occurs in a patient using ULT

ULT: allopurinol, febuxostat

A
  • True
17
Q

Colchicine - brand/generic, dosing, CIs, warnings, SEs

A

Colchicine (Colcrys)

Dosing (Treatment):
* Start within 36 hours of symptom onset

  • Wait 12 hours after a treatment dose before resuming prophylaxis dosing
  • 1.2 mg PO followed by 0.6 mg in 1hr
  • Do not exceed a total of 1.8 mg in 1 hr or 2.4 mg/day

Contraindications:
* Do not use in combination with a P-gp or strong CYP3A4 inhibitor with renal and/or hepatic impairment

Warnings:
* Myelosuppression

  • ↑ myopathy risk

Side effects:
* Diarrhea, nausea, myopathy, neuropathy

18
Q
A
18
Q

NSAIDs - medications

A
  • Indomethacin (Indocin)
  • Naproxen (Aleve)
  • Celecoxib (Celebrex)
19
Q

Avoid use of NSAIDs in severe __ disease and __ risk.

Fill in the blanks

A
  • Renal
  • CVD
20
Q

Steroids - formulations, SEs

A

Formulations:
* Steroids are given PO, IM, IV, intra-articular or as ACTH (adrenocorticotropic hormone), which triggers endogenous glucocorticoid secretion

SEs:
* ↑BG,↑BP, ↑ appetite, insomnia

21
Q

Steroids: medications

A
  • Prednisone/Prednisolone
  • Methylprednisolone (Medrol, Solu-Medrol)
22
Q

T/F: Methylprednisolone should be initiated intra-articularly if 1-2 large joints involved

A
  • True
23
Q

List colchicine DIs

A

Fatal toxicity:
CYP3A4 inhibitors or strong P-gp inhibitors

24
Q

What is the first-line prophylactic treatment for gout?

A

Chronic ULT

  • Initiate if one or more gout attacks are experienced or joint damage or tophi has occured
  • Allopurinol, xanthine oxidase inhibitor (XOI) is the first line drug
  • XOI stops the production of UA and it should be titrated up slowly to lower UA level of <6 mg/dL
  • High risk of allopurinol hypersensitivity reaction: HLA-B * 5801 allele screening

Colchicine, NSAIDs or steroids
* Used as prophylaxis when starting ULT to reduce the risk of attacks

25
Q

What is the second-line prophylactic treatment for gout?

A

Probenecid
* Uricosuric that is used when XOIs are contraindicated or not tolerated or can be added when the UA level is not at goal despite maximum doses of XOIs

  • It inhibits reabsorption of UA in the proximal tubule of the nephrone and requires adequate renal function to be effective

Lesinurad
* Uricosuric that is taken with the XOI

Pegloticase
* Recombinat uricase enzyme that converts UA to an inactive metabolite that can be easily excreted

  • It is reserved for severe, refractory disease
26
Q

Allopurinol - brand/generic, MOA, warnings, SEs

A

Allopurinol (Zyloprim, Aloprim)

MOA:
* Decrease uric acid production

Warnings:
* Hypersensitivity reactions (severe rash, including SJS/TEN, DRESS); HLA-B * 5801 testing prior to use if high risk and do not use if positive

  • Hepatotoxicity

Side effects:
* Rash, acute gout attacks, nausea

Use with colchicine or an NSAID for the first 3-6 months due to the high rate of gout attacks

27
Q

Febuxostat - brand/generic, MOA, BW, warnings, SEs

A

Febuxostat (Uloric)

MOA:
* Decrease UA production

Boxed warnings:
* Use should be limited to those who cannot tolerate allopurinol as there is an increased risk of CV death compared to allopurinol in patients with CV disease

Warnings:
* Hepatotoxicity
* Serious skin reactions (SJS/TEN, DRESS)

Side effects:
* Increased LFTs

Use with colchicine or an NSAID for the first 3-6 months due to the high rate of gout attacks

28
Q

Uricosurics - MOA, brand/generic

A

Probenecid
* Increases beta-lactam levels

Lesunurad
* Taken with allopurinol or febuxostat

MOA:
* Inhibit reabsorption of UA in the kidneys, which increases UA excretion

29
Q

XOI - DIs

A
  • They increase the concentration of mercaptopuriine, the active metabolite of azathioprine
30
Q

Probenecid - DIs

A
  • ADRs can occur when used with beta-lactams to increase the concentration
31
Q

Recombinant Uricase - MOA, BWs, CIs

A

Pegloticase (Krystexxa)

MOA:
* Converts UA to allantoin, which is excreted

Boxed warnings:
* Anaphylactic reactions - premedicate with antihistamines and steroids

Contraindications:
* G6PD deficiency

  • Do not use in combination with allopurinol, febuxostat or probenecid (increases risk of anaphylaxis)
32
Q

Which medication is used to treat tumor lysis syndrome (TLS)?

A
  • Rasburicase (Elitek) - a urate-oxidase enzyme
33
Q

When is the use of rasburicase contraindicated?

A
  • G6PD deficiency

Naplex (20 decks)

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