Gout

Question 1

(?) is a common form of inflammatory arthritis characterised by raised uric acid concentration in the blood and the deposition of urate crystals in joints and other tissues

Answer 1

Gout

Question 2

Gout is a common form of inflammatory arthritis characterised by raised (?) concentration in the blood and the deposition of urate crystals in joints and other tissues

Answer 2

Uric acid

Question 3

Gout is a common form of inflammatory arthritis characterised by raised uric acid concentration in the blood and the deposition of (?) crystals in joints and other tissues

Answer 3

Urate

Question 4

What are the three distinct phases of gout?

Answer 4

1. Asymptomatic hyperuricaemia
2. A period of acute attacks followed by variable intervals (months to years) with no symptoms
3. Chronic tophaceous gout, where people have nodules affecting joints

Question 5

The management of gout in those under (?) years of age require specialist supervision

Answer 5

30

Question 6

Which two drugs can you use to treat acute attacks of gout?

Answer 6

Colchicine

High doses of an NSAID (excluding aspirin)

Question 7

If you prescribe a high dose of an NSAID to treat an acute attack of gout, what must you also prescribe?

Answer 7

A gastro-protective drug (e.g. PPI)

Question 8

What is the limitation of colchicine in the management of acute attacks of gout?

Answer 8

Toxicity at higher doses

Question 9

What is the advantage of colchicine in the management of acute attacks of gout? (2)

Answer 9

1. Does not induce fluid retention (unlike NSAIDs)

2. Can be co-administered with anticoagulants

Question 10

What should you do if acute attacks of gout has an inadequate response to monotherapy with either colchicine or high dose NSAIDs?

Answer 10

Combination therapy (colchicine + NSAIDs)

Question 11

What procedure is an option for the management of an acute monoarticular gout attack?

Answer 11

Joint aspiration and intra-articular injection of a corticosteroid

Question 12

In patients having an acute attack of gout who cannot tolerate NSAIDs or colchicine, and when an intra-articular injection is unsuitable, what are the two alternative treatment options?

Answer 12

1. Short course of oral corticosteroids

2. Injection of IM corticosteroids

Question 13

What is the definition of frequent gouty arthritis attacks?

Answer 13

At least 3 in the previous 12 months

Question 14

What treatment option can be considered for frequent gouty arthritis attacks (at least 3 in the previous 12 months) in patients who have an inadequate response to standard treatment?

Answer 14

An interleukin-1 inhibitor (e.g. canakinumab)

Question 15

Name two drugs used for the long-term control of gout?

Answer 15

Allopurinol
Febuxostat

Xanthine-oxidase inhibitors that reduce the formation of uric acid from purines

Question 16

What is the mode of action of allopurinol and febuxostat?

Answer 16

Xanthine-oxidase inhibitors that reduce the formation of uric acid from purines

Question 17

What is the first-line urate-lowering therapy for long-term control of gout?

Answer 17

Allopurinol

• Oral: initially 100 mg daily, adjust according to plasma uric acid concentration
• take after food

Question 18

If allopurinol is contraindicated or not tolerated for the long-term control of gout, what is the alternative option?

Answer 18

Febuxostat

- Oral: initially 80 mg once daily, can be increased to 120 mg once daily

Question 19

What type of drugs can be prescribed by a specialist in patients with gout who are resistant to or are intolerant of xanthine-oxidase inhibitor?

Answer 19

Uricosuric drugs

• Sulfinopyrazne
• Benzbromarone

Increase the excretion of uric acid in the urine

Can be combined with xanthine-oxidase inhibitors in patients who have an inadequate response to monotherapy

Question 20

How do uricosuric drugs help in the management of long-term control of gout?

Answer 20

Increase the excretion of uric acid in the urine

Specialist use only

Can be combined with xanthine-oxidase inhibitors in patients who have an inadequate response to monotherapy

Question 21

When do you start urate-lowering therapy in a patient who requires long-term control of gout?

Answer 21

After the inflammation in an acute attack has settled

Question 22

Following an acute attack of gout, how long should colchicine be continued as prophylaxis in patients who will start urate-lowering therapy for long-term control of gout?

Answer 22

Up to 6 months

Colchicine is used as prophylaxis for up to 6 months as the initiation or up-titration of urate-lowering therapy may precipitate an acute attack of gout

Alternative to colchicine as prophylaxis: low-dose NSAID + gastro-protection

Question 23

Do you stop urate-lowering therapy if an acute attack of gout occurs?

Answer 23

NO

Continue urate-lowering therapy at the same dosage, while treating the acute attack

Question 24

What should you advise to patients with gout and a history of urolithiasis?

Answer 24

Ensure adequate daily fluid intake and avoid dehydration

Question 25

(Acidization/Alkalinisation?) of the urine with potassium citrate can be considered in recurrent kidney stone formers

Answer 25

Alkalinisation

Question 26

Alkalinisation of the urine with (?) can be considered in recurrent kidney stone formers

Answer 26

potassium citrate

Question 27

Is allopurinol used during an acute attack of gout or for long-term control of gout?

Answer 27

Long-term control of gout

Question 28

What is a common side effect of allopurinol?

Answer 28

Rash Discontinue therapy if rash occurs. If rash was mild re-introduce cautiously but discontinue immediately if recurrence

Question 29

What do you do if a patient on allopurinol develops a rash?

Answer 29

Discontinue therapy if rash occurs. | If rash was mild re-introduce cautiously but discontinue immediately if recurrence

Question 30

Can a pregnant patient take allopurinol?

Answer 30

ONLY if no safer alternative and disease carriers risk for mother or child Toxicity not reported

Question 31

Are dose adjustments of allopurinol required in hepatic or renal impairment?

Answer 31

Renal impairment Max. initial dose 100 mg daily, increased only if response inadequate; in severe impairment, reduce daily dose below 100 mg, or increase dose interval; if facilities available, adjust dose to maintain plasma-oxipurinol concentration below 100 micromol/litre.

Question 32

What is the mode of action of canakinumab?

Answer 32

A recombinant human monoclonal antibody that selectively inhibits interleukin-1 beta receptor binding

Question 33

When would you consider using the interleukin-1 inhibitor, canakinumab, in the treatment of gout?

Answer 33

Acute attacks of gout in patients with frequent gouty arthritis attacks (at least 3 in the previous 12 months) in patients who have an inadequate response to standard treatment

Question 34

Is colchicine used during an acute attack of gout or for long-term control of gout?

Answer 34

Acute attack of gout

Question 35

Apart from acute gout, what is the other indication for the use of colchicine?

Answer 35

Prophylaxis of familial Mediterranean fever (recurrent polyserositis)

Question 36

The dose of colchicine needs to be (?) if concurrent use of inhibitors of CYP3A4 or P-glycoprotein inhibitors

Answer 36

reduced

Question 37

The dose of colchicine needs to be reduced if concurrent use of (?) of CYP3A4 or P-glycoprotein inhibitors

Answer 37

inhibitors

Question 38

In elderly patients, when is a prescription of colchicine potentially inappropriate (STOPP criteria)?

Answer 38

1. If eGFR less than 10 mL/miunute/1.73 m^2 (risk of toxicity) 2. For chronic treatment of gout where there is no contraindication to a xanthine-oxidase inhibitor

Question 39

Are dose adjustments of colchicine required in hepatic or renal impairment?

Answer 39

Renal impairment Reduce dose or increase dosage interval if eGFR 10–50 mL/minute/1.73 m^2. Avoid if eGFR less than 10 mL/minute/1.73 m^2.

Question 40

Can colchicine be used during pregnancy?

Answer 40

NO Teratogenicity in animal studies

Question 41

What are the common side effects of colchicine? (4)

Answer 41

Abdominal pain Diarrhoea Nausea Vomiting

Question 42

Is febuxostat used during an acute attack of gout or for long-term control of gout?

Answer 42

Long-term control of gout

Question 43

What are the common side effects of febuxostat?

Answer 43

1. Diarrhoea 2. Gout aggravated 3. Headache 4. Hepatic disorders 5. Nausea 6. Oedema 7. Skin reactions

Question 44

Are dose adjustments of febuxostat required in hepatic or renal impairment?

Answer 44

Hepatic impairment Manufacturer advises max. 80 mg daily in mild impairment; no dose information available in moderate to severe impairment.

Question 45

What needs to be monitored before and during treatment with febuxostat?

Answer 45

LFTs