Drugs to Treat Gout

Question 1

Gout is associated with what medical conditions and lifestyle habits?

Answer 1

Purine-rich diet
Excess EtOH consumption
Obesity
HTN
Hyperlipids
T2DM
Hyperuricemia ( above 6.8 mg/dL)

Question 2

Hyperuricemia is most often caused by….?

Answer 2

Decreased excretion of uric acid by the kidneys (90%)

Could also be caused by overproduction of uric acid (10%)

Question 3

What are tophi?

Answer 3

Urate crystal deposits around joint that promote inflammation and joint destruction

Question 4

What two drugs are used to treat acute gout?

Answer 4

NSAIDs

Colchicine

Question 5

NSAIDs

Indications in Gout

Answer 5

Decrease pain and disability due to acute attack

Used as prophylaxis with other anti-gout drugs

Question 6

Which NSAID should NOT be used in gout? Why?

Answer 6

Aspirin and salicylates should not be used in gout

Both inhibit uric acid secretion at low doses, which can INDUCE gout

Question 7

Colchicine

Indications in gout

Answer 7

Anti-inflammatory, but NOT analgesic

Effective within first 24-48 hrs of acute gout attack

Question 8

Colchicine

MOA

Answer 8

Prevents tubulin polymerization into microtubules, which prevents leukocyte migration and phagocytosis

Question 9

Colchicine

AEs

Answer 9

Nausea
Diarrhea
Vomit

Question 10

What drugs are used to treat Chronic Gout?

Answer 10

Probenecid
Lesinurad

Allopurinol
Febuxostat

Pegloticase

Question 11

Probenecid and Lesinurad

MOA

Answer 11

Block URAT1 anion transporter in renal tubules, thus increasing the urine concentration of uric acid

Question 12

Probenecid

Indications

Answer 12

Used in patients who under-excrete uric acid

Should NOT be given until 2-3 weeks after initial attack

Question 13

Probenecid

Contraindications

Answer 13

Patients who overproduce uric acid (increases kidney stone risk)

Patients with kidney stones or renal insufficiency

Do NOT give until 2-3 weeks after initial acute gout attack

Question 14

Allopurinol and Febuxostat

MOA

Answer 14

Inhibit Xanthine Oxidase to prevent conversion of hypoxanthine or guanine to uric acid

Question 15

Allopurinol and Febuxostat

Indications

Answer 15

Patients with high uric acid synthesis

Recurrent kidney stones

Renal impairment

Tophi

Question 16

Allopurinol and Febuxostat

AEs

Answer 16

Can induce acute gouty attack if NSAID prophylaxis is not provided

Rarely, may get rash, leukopenia, thrombocytopenia

Question 17

Describe Allopurinol Hypersensitivity Syndrome.

Prevalence
Symptoms
Who gets it?

Answer 17

Rare (less than 0.1%)

Symptoms: erythematous rash, eosinophilia, fever, hepatitis, acute renal failure

Seen in patients who take high doses of allopurinol in presence of renal impairment and/or diuretics

Question 18

Allopurinol and Febuxostat

Drug Interactions

Answer 18

Can increase levels of 6-mercaptopurine and Azathioprine, which can cause toxic effects

Question 19

What drug should be used if the patient has chronic gout and is an UNDERSECRETER (less than 700 mg/dL urine) or uric acid?

Answer 19

Probenecid (gout caused by undersecretion of uric acid)

Question 20

What drug should be used if the patient has chronic gout and is an OVERSECRETER (more than 700 mg/dL urine) or uric acid?

Answer 20

Allopurinol (gout caused by overproduction of uric acid)

Question 21

How long is effective chronic gout treatment indicated for?

Answer 21

Lifelong treatment

Question 22

Goal of Gout treatment

Answer 22

Reduce serum uric acid levels to below 6 mg/dL (attacks tend to happen above 6.8 mg/dL)

Question 23

Pegloticase

MOA

Answer 23

Uricase enzyme from pigs that converts insoluble uric acid to readily excretable soluble product

Question 24

Pegloticase

Indications

Answer 24

Used in patients with acute symptomatic gout not controlled by other drugs