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Notes/Facts/Brand vs Generic Part 2 > Gout > Flashcards

Gout Flashcards

1
Q

For a case, do NOT choose treatment unless a gout attack has occurred

A
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2
Q

Uric acid comes from breaking down __________

A

purines, often in foods and medications

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3
Q

Gout is a type of arthritis caused by _______

A

a buildup of Uric acid crystals, primarily in the joints.

Uric acid crystallization

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4
Q

Symptoms of Gout include:

A

Severe pain, swelling and redness in joints.
Sudden onset

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5
Q

Uric acid is produced as an end product of ________

A

purine metabolism

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6
Q

Uric acid is mainly excreted, _____

A

renally (primarily)

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7
Q

a normal serum UA level is ______________ in females

a normal serum UA level is ______________ in males

A
  • 2-6.5 mg/dL
  • 3.5-7.2 mg/dL
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8
Q

Uric acid can crystallize in the joints called __________. This results in a severe painful gout attack with burning and swelling of the affected joint.

If left untreated, the attacks ____________

A

tophi

can occur repeatedly and damage the joints, tendons and other tissues.

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9
Q

Gout typically occurs in one joint, most often the _______________

A

metatarsophalangeal joint (MTP, the big toe)

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10
Q

Risk factors for Gout include:

A

-male sex
- obesity
- EXCESSIVE ALCOHOL (particularly beer)
- hypertension
- chronic kidney disease
- lead intoxication
- advanced age
- using medications that increase UA

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11
Q

Drugs that increase Uric Acid include:

A
  • aspirin, lower doses
  • Calcineurin inhibitors (tacrolimus & cyclosporine)
  • Diuretics (loops & thiazides)
  • Niacin
  • Pyrazinamide- “RIP” - regimen for Tuberculosis
  • select chemotherapy (with tumor lysis syndrome)
  • select pancreatic enzyme products
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12
Q

Niacin has a Contraindication for severe Gout but when it is controlled __

A

can use it.
But what Gout isn’t severe.
So we wouldn’t want to use during a Gout attack

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13
Q

Changing the diet can lower risk of Gout. Foods to avoid include: _________

Limit fruit juices, table sugar, sweetened drinks and desserts, salt, beef, lamb, pork, and seafood with high purine content (sardines, SHELLFISH)

Encourage a healthy diet: low-fat dairy products, vegetables and HYDRATION.

A

ORGAN MEATS, high-fructose corn syrup, alcohol

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14
Q

Asymptomatic hyperuricemia is NOT ______

A

treated with drugs

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15
Q

Gout Treatment Basics

-
-
2) Treat chronically to prevent future attacks (prevention of future attacks)
-
-

-

A

1)
- Colchicine
- Steroids
-NSAIDs

2)
- Xanthine oxidase inhibitor (XOI): allopurinol (preferred) or febuxostat
*** acute Tx needed when starting to prevent a flare

3)
-add on probenecid or lesinurad to daily XOI
- replace the XOI with IV pegloticase (Krystexxa)

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16
Q

The prophylactic drugs are used to lower (UA) Uric acid levels, with a goal UA level of______________

A

less than < 6mg/dL

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17
Q

An acute gout flare can occur when ___________

A

an XOI is started, so give initially with colchicine or an NSAID

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18
Q

The enzyme Uricase, is responsible for _____

A

the conversion of uric acid to Allantoin

19
Q

The enzyme Xanthine oxidase is responsible for________

A

the conversion of Hypoxanthine —–> Xanthine &
Xanthine —-> Uric acid

20
Q

(TLS)

A

Tumor Lysis Syndrome

21
Q

(TLS) Tumor Lysis Syndrome:

A

is an acute, potentially life-threatening complication of some major types of chemotherapy. When cells are “lysed” open, purines are released into the blood and quickly converted to UA. This can cause acute gout and significant abnormalities, which can lead to renal failure, cardiac arrhythmias and potential death.

22
Q

ULT

A

Urate Lowering Therapy

23
Q

Celebrex

Class:
Indications:
MOA:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Celecoxib

Class: NSAID, selective COX-2 inhibitor

Indications:

Dosing: 200mg PO BID, discontinue 2-3 days after attack resolved

MOA:

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

24
Q

Elitek

Class:
Indications:
MOA:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Rasburicase

  • urate oxidase enzyme
  • ## used in the Tx of (TLS) Tumor Lysis Syndrome
  • Contraindicated: in those with G6PD deficiency. DC immediately and permanently in any patient developing hemolysis.
25
Q

Colcrys

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

colchicine

Class: Antigout medication

Indications: Gout attack
Major substrate of CYP3A4 and P-gp

MOA: disrupts cytoskeletal functions by inhibiting B-tubulin polymerization into microtubules, preventing activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms.

Dosing:
Tx: 1.2mg (two of the 0.6 tablets) followed by 0.6mg in 1 hour (do not exceed a total of 1.8mg in 1 hour or 2.4mg/day)
If CrCl < 30mL/min treatment dose is the same, but do not give again for 2 weeks.
Prophylaxis: 0.6mg once or twice daily
CrCl < 30mL/min: decrease to 0.3mg/day

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

Warnings: Myelosuppression, neuromuscular toxicity (including rhabdomyolysis), if possible, do not use with cyclosporine, diltiazem, verapamil, gemfibrozil or statins as these drugs increase myopathy risk

Side Effects: Diarrhea, nausea, myopathy, neuropathy (dose-dependent), decreases vitamin B12.

Pearls/Notes:
-Start within 36 hours of symptom onset (for treatment)
wait 12 hours after a treatment dose before resuming prophylaxis dosing.

-Maintain adequate fluid intake.
-Do not use more than 3 tablets in an hour
-Do not use more than 4 tablets in 24 hours
-Do not take the second dose if you have stomach upset, nausea or diarrhea

Drug-Drug/Food interactions:

Fatal toxicity can occur if combined with strong CYP3A4 inhibitors, such as clarithromycin.
OR
strong inhibitor of P-gp such as cyclosporine
If used with a strong CYP3A4 inhibitor, dose is reduced and should not be repeated no earlier than 3 days.
If using a moderate CYP3A4 inhibitor, the maximum dose for an acute attack is 1.2mg

26
Q

Mitigare

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

colchicine

Class: Antigout medication

Indications: Gout attack
Major substrate of CYP3A4 and P-gp

MOA: disrupts cytoskeletal functions by inhibiting B-tubulin polymerization into microtubules, preventing activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms.

Dosing:
Tx: 1.2mg (two of the 0.6 tablets) followed by 0.6mg in 1 hour (do not exceed a total of 1.8mg in 1 hour or 2.4mg/day)
If CrCl < 30mL/min treatment dose is the same, but do not give again for 2 weeks.
Prophylaxis: 0.6mg once or twice daily
CrCl < 30mL/min: decrease to 0.3mg/day

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

Warnings: Myelosuppression, neuromuscular toxicity (including rhabdomyolysis), if possible, do not use with cyclosporine, diltiazem, verapamil, gemfibrozil or statins as these drugs increase myopathy risk

Side Effects: Diarrhea, nausea, myopathy, neuropathy (dose-dependent), decreases vitamin B12.

Pearls/Notes:
-Start within 36 hours of symptom onset (for treatment)
wait 12 hours after a treatment dose before resuming prophylaxis dosing.

-Maintain adequate fluid intake.
-Do not use more than 3 tablets in an hour
-Do not use more than 4 tablets in 24 hours
-Do not take the second dose if you have stomach upset, nausea or diarrhea

Drug-Drug/Food interactions:

Fatal toxicity can occur if combined with strong CYP3A4 inhibitors, such as clarithromycin.
OR
strong inhibitor of P-gp such as cyclosporine
If used with a strong CYP3A4 inhibitor, dose is reduced and should not be repeated no earlier than 3 days.
If using a moderate CYP3A4 inhibitor, the maximum dose for an acute attack is 1.2mg

27
Q

Gloperba

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

colchicine

Class: Antigout medication

Indications: Gout attack
Major substrate of CYP3A4 and P-gp

MOA: disrupts cytoskeletal functions by inhibiting B-tubulin polymerization into microtubules, preventing activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms.

Dosing:
Tx: 1.2mg (two of the 0.6 tablets) followed by 0.6mg in 1 hour (do not exceed a total of 1.8mg in 1 hour or 2.4mg/day)
If CrCl < 30mL/min treatment dose is the same, but do not give again for 2 weeks.
Prophylaxis: 0.6mg once or twice daily
CrCl < 30mL/min: decrease to 0.3mg/day

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

Warnings: Myelosuppression, neuromuscular toxicity (including rhabdomyolysis), if possible, do not use with cyclosporine, diltiazem, verapamil, gemfibrozil or statins as these drugs increase myopathy risk

Side Effects: Diarrhea, nausea, myopathy, neuropathy (dose-dependent), decreases vitamin B12.

Pearls/Notes:
-Start within 36 hours of symptom onset (for treatment)
wait 12 hours after a treatment dose before resuming prophylaxis dosing.

-Maintain adequate fluid intake.
-Do not use more than 3 tablets in an hour
-Do not use more than 4 tablets in 24 hours
-Do not take the second dose if you have stomach upset, nausea or diarrhea

Drug-Drug/Food interactions:

Fatal toxicity can occur if combined with strong CYP3A4 inhibitors, such as clarithromycin.
OR
strong inhibitor of P-gp such as cyclosporine
If used with a strong CYP3A4 inhibitor, dose is reduced and should not be repeated no earlier than 3 days.
If using a moderate CYP3A4 inhibitor, the maximum dose for an acute attack is 1.2mg

28
Q

Indocin

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

indomethacin

Class: NSAID

Indications: Approved for pain relief in acute gout attack

MOA:

Dosing: 50mg PO TID until attack resolved

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes: Avoid Use in severe renal disease (UA is renally cleared and patients with gout often have renal insufficiency) and CVD risk, bleeding (risk is lower with short duration of use)

Drug-Drug/Food interactions:

29
Q

Aleve

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

naproxen

Class: NSAIDs

Indications: Approved for Gout

MOA:

Dosing: 500mg PO BID until attack resolved

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes: Avoid use in severe renal disease, cardiac disease, bleeding

Drug-Drug/Food interactions:

30
Q

Sulindac

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Class:

Indications: Approved for gout

MOA:

Dosing: 200mg PO BID until attack resolved

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

31
Q

Intensol

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

prednisone

Class: Corticosteroid

Indications: acute gout flare

MOA:

Dosing:

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

32
Q

Rayos

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

prednisone

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

33
Q

Millipred

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

prednisolone

34
Q

Medrol

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Class:

Indications:

MOA:

Dosing: oral dose pack

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

35
Q

Solu-Medrol

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Class:

Indications: Acute gout attack therapy

MOA:

Dosing: Intra-articular, if 1-2 large joints involved

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

36
Q

triamcinolone

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

37
Q

Zyloprim

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

allopurinol

Class: Xanthine Oxidase Inhibitor

Indications: Chronic Urate Lowering therapy for prophylactic treatment in Gout

MOA: decreases uric acid production in the body by blocking the responsible enzyme Xanthine Oxidase for its production.

Dosing: Start at 100mg daily, then titrate slowly up until Uric acid is < 6mg/dL (doses > 300mg can be necessary and should be divided BID)

CrCl < or = 30mL/min: Start at 50mg daily, increase gradually up 300mg/day

Take after a meal (with food in stomach) to decrease nausea.

Contraindications:

Warnings: Hypersensitivity reactions including severe rash (SJS/TEN/DRESS); HLA-B*5801 testing prior to use if high risk (patients of Asian descent) and DO NOT use if +, hepatotoxicity.

Side Effects: rash, acute gout attacks, nausea, diarrhea, increased LFTs

Monitoring: CBC/LFTs/renal function

Pearls/Notes:
Higher doses are used for TLS
Take after a meal to reduce stomach upset (higher doses can be divided). Also drink plenty of fluids throughout the day.

**-due to the high rate of Gout attacks when beginning (ULT) Uate Lowering Therapy, use colchicine 0.6mg once or twice daily or an NSAID for the first 3-6 months.

Drug-Drug/Food interactions:
allopurinol increases the concentration of mercaptopurine, the active metabolite of azathioprine. Do not use either with allopurinol or decrease dose and monitor for toxicity.

**antacids can decrease allopurinol absorption.

38
Q

Aloprim

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

allopurinol

Class:

Indications: Chronic Urate Lowering therapy for prophylactic treatment

MOA: decreases uric acid production in the body by blocking the responsible enzyme Xanthine Oxidase for its production.

Dosing:

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

39
Q

Uloric

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

febuxostat

Class: Xanthine Oxidase Inhibitor

Indications: Chronic Urate Lowering therapy for prophylactic treatment

MOA: decreases uric acid production in the body by blocking the responsible enzyme Xanthine Oxidase for its production.

Dosing: 40-80mg daily (Max 120mg/day)
-Start at 40mg daily, may increase to 80mg daily if UA is NOT < 6mg/dL after 2 weeks.
-If CrCl < 30mL/min; (Max 40mg daily)

Boxed Warning: Increased risk of Cardiovascular death compared to allopurinol in patients with established CV disease; use should be limited to those who cannot tolerate allopurinol or if allopurinol is not effective

Contraindications: Do NOT USE with mercaptopurine or azathioprine

Warnings: Hepatotoxicity, possible MI or stroke, gout attack, hypersensitivity and serious skin reactions including SJS/TEN/DRESS

Side Effects: rash, nausea, increased LFTs,

Monitoring: LFTs

Pearls/Notes:
**-due to the high rate of Gout attacks when beginning (ULT) Uate Lowering Therapy, use colchicine 0.6mg once or twice daily or an NSAID for the first 3-6 months.

Drug-Drug/Food interactions:
increases the concentration of mercaptopurine, the active metabolite of azathioprine. Do not use febuxostat with either!!

40
Q

Zurampic

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

lesinurad

Class: Uricosuric

Indications: Chronic Urate (Uric acid) Lowering therapy for prophylactic treatment

MOA: inhibits reabsorption of Uric acid in the kidneys, increasing Uric acid secretion

Dosing: 200mg daily in the morning with a Xanthine oxidase inhibitor (allopurinol or febuxostat); if Xanthine oxidase inhibitor is stopped, then stop lesinurad.
-Only initiate if CrCl > or = to 45mL/min
- If CrCl < 30mL/min: Contraindicated

Boxed Warning: ONLY TO BE USED WITH Xanthine Oxidase Inhibitor, NOT FOR MONOTHERAPY. ACUTE RENAL FAILURE MORE COMMON IN MONOTHERAPY.

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes: Use only with a (XOI) Xanthine Oxidase inhibitor if UA goals not reached with XOI alone; keep hydrated.

Drug-Drug/Food interactions:

41
Q

Duzallo

A

allopurinol/lesinurad

42
Q

Probenecid

Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

Class: Uricosuric

Indications: Chronic Urate (Uric acid) Lowering therapy

MOA: inhibits reabsorption of uric acid in the kidneys, which increases Uric acid excretion

Dosing: Start 250mg BID, can increase to 2g/day

If CrCl < 30mL/min then AVOID USE

Contraindications: Do NOT use with aspirin therapy, blood dyscarsias, UA kidney stones (nephrolithiasis), children < 2 years, initiation in acute gout attack

Warnings: decreased effectiveness with CrCl < 30mL/min (ACR guidelines; do not use if CrCl < 50mL/min), DO NOT USE with G6PD deficiency

Side Effects: hypersensitivity reactions, hemolytic anemia

Monitoring:

Pearls/Notes:
-Can be used to increase beta-lactam levels by decreasing beta-lactam excretion. This will increase risk for adverse reactions associated with beta-lactams.
-May be useful in patients with good renal function or if taking medications that increase uric acid levels (loop diuretics)

Drug-Drug/Food interactions:
can decrease the renal clearance of other medications taken concurrently, including aspirin, methotrexate, theophylline, penicillin’s, etc.

43
Q

Krystexxa

cra-stex-za
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

pegloticase
(injection)

Class: Recombinant Uricase

Indications: Chronic Urate (Uric acid) Lowering therapy for prophylactic treatment of Gout
for refractory cases only

MOA: increasing conversion of Uric acid to Allantoin, which is excreted.

Dosing: 8mg IV every 2 weeks

Boxed Warnings: Anaphylactic reactions - monitor and premedicate with antihistamines and steroids, risk is highest if UA is > 6mg/dL; life-threatening hemolytic reactions and methemoglobinemia may occur with G6PD deficiency.

Contraindications: G6PD deficiency

Warnings: Acute Gout flares can occur upon initiation; an NSAID or colchicine should be given 1 week prior to infusion and continued for at least 6 months.

Side Effects: Antibody formation, gout flare, infusion reactions, nausea, bruising, urticaria, erythema

Monitoring:

Pearls/Notes: DO NOT USE in combination with allopurinol, febuxostat or probenecid (increased risk of anaphylaxis)

Drug-Drug/Food interactions:

44
Q

Uric Acid Production and where Drug Treatment intervenes:

A

Adenosine —> Hypoxanthine —> Xanthine —> Uric acid

Notes/Facts/Brand vs Generic Part 2 (14 decks)

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