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702 > Gout > Flashcards

Gout Flashcards

1
Q

What does the epidemiology of gout look like?

A
  • Increased age and males at risk
  • Linked to comorbid conditions, diet, and medications
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2
Q

What is the concentration where uric acid starts becoming insoluble?

A

6.7 mg/dL

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3
Q

What disease states can promote hyperuricemia?

A
  • Diabetes
  • HLD
  • Obesity
  • Renal insufficiency/CKD
  • HTN
  • Organ transplantation
  • CHF
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4
Q

What are uricosuric foods/drinks? (can lower uric acid)

A
  • Coffee
  • Dairy
  • Vitamin C
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5
Q

What foods/drinks can raise uric acid?

A
  • Meat
  • Seafood
  • Beer/liquor
  • Soft drinks
  • Fructose
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6
Q

What medications can raise uric acid?

A
  • Thiazides
  • Loops diuretics
  • Nicotinic acid
  • Low dose aspirin
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7
Q

What medications can lower uric acid?

A

Losartan (use over thiazides)
Fenofibrate (use over nicotinic acid)

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8
Q

What does a gout flare look like?

A
  • <24 severe pain, erythema, swelling
  • Single or multiple joints (usually big toe)
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9
Q

What can exacerbate gout flares?

A
  • Alcohol
  • High purine ingestion
  • Stress
  • Certain medications (including UA lowering)
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10
Q

How is acute gout treated?

A

(Reduce pain and duration of attacks)
NSAIDs
Colchicine
Corticosteroids (oral, IA)

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11
Q

When should NSAIDs be used for a flare?

A

<24h of flare onset

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12
Q

When should you avoid NSAIDs?

A
  • Renal insufficiency/failure
  • Bleeding disorders or anticoagulated
  • PUD
  • CHF
  • Age >75
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13
Q

How should colchicine be dosed for a flare?

A

1.2 mg PO then 0.6 mg 1 hour later
(may require more)

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14
Q

How should colchicine be dosed for prophylaxis?

A

0.6 mg PO QD or QOD

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15
Q

When should you avoid colchicine?

A
  • GI problems
  • Renal dysfunction/elderly (rhabdomyolysis risk)
  • CYP3A4, PGP, fibrates, statins (myopathy)
  • Severe hepatic impairment
  • Dose adjust for renal/hepatic impairment
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16
Q

T/F: you must lower the dose of colchicine if a patient is on a CYP3A4/PGP inhibitor and has renal failure

A

FALSE: it is contraindicated in this situation

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17
Q

Which strong CYP3A4 inhibitors interact with colchicine?

A
  • Clarithromycin
  • Darunavir/ritonavir
  • Itraconazole
  • Ketoconazole
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18
Q

Which moderate CYP3A4 inhibitors interact with colchicine?

A
  • Diltiazem
  • Erythromycin
  • Fluconazole
  • Verapamil
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19
Q

Which PGP inhibitors interact with colchicine?

A
  • Cyclosporine
  • Amiodarone
  • Ranolazine
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20
Q

How should colchicine be adjusted with strong CYP3A4 inhibitors?

A

Acute: 0.6 mg then 0.3 mg 1 hour later, dose repeated no earlier than 3 days

Prophylaxis: 0.3 QOD to 0.3 QD

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21
Q

How should colchicine be adjusted with moderate CYP3A4 inhibitors?

A

Acute: 1.2mg, dose repeated no earlier than 3 days

Prophylaxis: 0.3-0.6 mg QD

22
Q

How should colchicine be adjusted with PGP inhibitors?

A

Acute: 0.6 mg, dose repeated no earlier than 3 days

Prophylaxis: 0.3 mg QOD to 0.3 QD

23
Q

How should intra-articular triamcinolone be dosed?

A

Large joint (knee): 40 mg

Medium joint (wrist, ankle, elbow): 30 mg

Small joint (toe, finger): 10 mg

24
Q

When should steroids be used?

A

Only 1-2 joints involved (intra-articular or oral)

25
Q

When are SYSTEMIC steroids required?

A

Polyarticular attacks

26
Q

When should you avoid steroids?

A
  • DM
  • CHF
  • GERD
  • PUD
27
Q

T/F: Steroids can be used in renal impairment

A

TRUE

28
Q

What drugs increase the risk of rash with allopurinol?

A
  • Amoxicillin
  • Thiazides
  • Ampicillin
  • ACEi
29
Q

What should you do if you develop a rash with allopurinol?

A

Discontinue -> might progress to SJS or DRESS

30
Q

What drugs should be avoided with allopurinol?

A

6-MP, azathioprine, theophylline, drugs that increase risk of rash

31
Q

What should you do if a patient is on allopurinol and warfarin?

A

Decrease their dose of allopurinol

32
Q

How is allopurinol dosed?

A

100 mg QD usually, increase q2-5 weeks until uric acid <6 mg/dL

50 mg QD for CKD stage 4 or worse

Max 800 mg QD

33
Q

When should you avoid febuxostat?

A
  • CrCl <30 mL/min
  • CV disease
34
Q

T/F: Febuxostat can be used as monotherapy anytime

A

FALSE: should be used with colchicine and an NSAID to prevent flares for the first 6 months

35
Q

T/F: Chronic therapy does not need to be stopped during a flare

A

TRUE

36
Q

What is the BBW on febuxostat?

A

Cardiovascular death with established CV disease

37
Q

What are contraindications to febuxostat?

A

6-MP, azathioprine, or theophylline

38
Q

When should probenicid be avoided?

A
  • CrCl <50 mL/min
  • History of nephrolithiasis
  • Use of penicillin, methotrexate, carbapenems, salicylates
39
Q

How should pegloticase be given?

A

IV 8 mg every 2 weeks for at least 2 hours
Premedicate with antihistamines and corticosteroids
Use with low dose colchicine or NSAIDs for first 6 months to prevent flares

40
Q

What is the BBW for pegloticase?

A

Infusion reactions

41
Q

What indicates a need for chronic therapy?

A

At least 1:
- Subcutaneous tophi
- Radiographic evidence of damage from gout
- Frequent flares (at least 2 per year)

42
Q

When can chronic therapy be considered?

A
  • History of 1 attack but less than 2 attacks per year
  • First gout flare with CKD (stage 3+), UA >9 mg/dL, urolithiasis
43
Q

T/F: Uric acid lowering treatment should be started during the flare if it is determined to be indicated

A

TRUE

44
Q

What is the first line agent for chronic therapy?

A

Allopurinol

45
Q

When should UA be monitored?

A

Every 2-5 weeks with increases in ULT intensity until goal is reached

46
Q

What is the general treatment flow chart for chronic therapy?

A

Allopurinol or febuxostat titrated to maximum dose, then add probenecid if needed

47
Q

When should flare prophylaxis be started?

A

When ULT is started

Continue for 3-6 months based on resolution of symptoms and presence of tophi

48
Q

When is prednisone or prednisolone indicated for prophylaxis?

A

NSAIDs/colchicine not tolerated or contraindicated

49
Q

When should we consider combination therapy for a gout flare?

A
  • Polyarticular attack
  • Not responding to monotherapy
50
Q

Can you use colchicine for a flare if they’re already using it for prophylaxis?

A

YES, as long as they haven’t used colchicine to treat a gout flare in the past 14 days

51
Q

How should steroids be dosed for a flare (not intra-articular)?

A

Prednisone 0.5 mg/kg per day for 5-10 days

52
Q

Which combination therapy should we avoid?

A

NSAIDs + PO steroids

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