Chapter 60: Gout

Question 1

What is gout?

Answer 1

It is a type of arthritis caused by build up of uric acid primarily in the joints

Question 2

What is uric acid produced as an end-product of?

Answer 2

Purine metabolism

Question 3

Which joint does gout typically occur in?

Answer 3

MTP (big toe)

Question 4

List drugs thar increase uric acid

Answer 4

• Low dose aspirin
• Cyclosporine
• Diuretics
• Niacin
• Pyrazinamide

Question 5

Foods to avoid in gout

Answer 5

Organ meats, high-fructose corn syrup and alcohol

Question 6

How is asymptomatic hyperuricemia treated?

Answer 6

It is not treated

Question 7

Once a gout attack occurs, what should uric acid be lowered to?

Answer 7

< 6 mg/dL

Question 8

Which drugs can be used for an acute gout attack?

Answer 8

NSAID, steroid or colchicine

Question 9

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

Answer 9

An intra-articular steroid injection

Question 10

What is the brand name of colchicine?

Answer 10

Colcrys

Question 11

What is the dosing for colchicine?

Answer 11

Two 0.6 mg tabs followed by 0.6 mg in 1 hr

Question 12

What is the maximum dose for colchicine?

Answer 12

Do not exceed 1.8 mg in 1 hr

Question 13

What is a contraindication for colchicine?

Answer 13

Do not use in combination with a P-gp or strong 3A4 inhibitor

Question 14

What are the warnings for colchicine?

Answer 14

Myelosuppression, increase myopathy risk

Question 15

What are the side effects of colchicine?

Answer 15

Diarrhea, nausea, myopathy, neuropathy

Question 16

When should colchicine be started for treatment?

Answer 16

Within 36 hrs of symptoms onset

Question 17

How long should you wait after a treatment dose of colchicine before resuming prophylactic dosing?

Answer 17

12 hrs

Question 18

What is the brand name of indomethacin?

Answer 18

Indocin

Question 19

Which NSAIDs can be used in gout?

Answer 19

Indomethacin, Naproxen, Celecoxib

Question 20

Which steroid can be given intra-articularly if 1-2 large joints are involved?

Answer 20

Methylprednisolone

Question 21

What can occur if colchicine is combined with strong CYP3A4 inhibitors?

Answer 21

Fatal toxicity

Question 22

Name a strong CYP3A4 inhibitor that can cause fatal toxicity when combined with colchicine.

Answer 22

Clarithromycin

Question 23

Name a strong inhibitor of P-gP that can cause fatal toxicity when combined with colchicine.

Answer 23

Cyclosporine

Question 24

If colchicine is used with a strong CYP3A4 inhibitor, how should the colchicine dose be adjusted?

Answer 24

Reduced and repeated no earlier than three days

Question 25

What is the recommended treatment for patients with gout who have experienced multiple attacks?

Answer 25

Chronic ULT ## Footnote ULT stands for urate-lowering therapy.

Question 26

What medications should be used as prophylaxis when starting chronic ULT?

Answer 26

Colchicine, steroids, or NSAIDs should be used as prophylaxis.

Question 27

What is the first-line ULT for treating gout?

Answer 27

Allopurinol, a xanthine oxidase inhibitor (XO1).

Question 28

Asian descent and African American patients should be screened for which allele before using allopurinol?

Answer 28

HLA-B*5801

Question 29

What is the target level of UA when titrating XOIs?

Answer 29

≤ 6 mg/dL.

Question 30

How should the dose of allopurinol be adjusted in patients with moderate or severe CKD?

Answer 30

Allopurinol is started at a lower dose.

Question 31

What is the second-line treatment if XOIs are contraindicated or not tolerated?

Answer 31

Probenecid, a uricosuric agent.

Question 32

What is the mechanism of action of probenecid?

Answer 32

Probenecid inhibits reabsorption of UA in the proximal tubule of the nephron, which increases UA excretion.

Question 33

What is required for probenecid to be effective?

Answer 33

Adequate renal function.

Question 34

What is pegloticase and when is it used?

Answer 34

Pegloticase is a recombinant uricase enzyme used for severe, refractory gout.

Question 35

Fill in the blank: The first-line ULT is _______.

Answer 35

allopurinol.

Question 36

What is the mechanism of action (MOA) of Xanthine Oxidase Inhibitors?

Answer 36

They decrease uric acid (UA) production.

Question 37

Allopurinol brand name

Answer 37

Zyloprim, Aloprim

Question 38

What are the warnings associated with Allopurinol?

Answer 38

Hypersensitivity reactions including severe rash; HLA-B*5801 testing prior to use & do not use drug if positive, hepatotoxicity.

Question 39

What are the side effects (SE) of Allopurinol?

Answer 39

Rash, acute gout attacks, nausea.

Question 40

To which population is Febuxostat limited?

Answer 40

Those who cannot tolerate allopurinol or allopurinol is not effective.

Question 41

What are the warnings and side effects (SE) of Febuxostat?

Answer 41

Increased LFTs, hepatotoxicity, serious skin reactions.

Question 42

Probenecid can be used to increase ____ levels

Answer 42

beta-lactam

Question 43

How is pegloticase administered?

Answer 43

IV

Question 44

Pegloticase BW

Answer 44

anaphylactic reactions - monitor and premedicate with antihistamines and steroids

Question 45

Pegloticase CI

Answer 45

G6PD deficiency

Question 46

T/F: Pegloticase cannot be used in combination with allopurinol, febuxostat or probenecid d/t increased risk of infection

Answer 46

True

Question 47

What do allopurinol and febuxostat increase the concentration of?

Answer 47

mercaptopurine