Gout Flashcards
(44 cards)
1
Q
For a case, do NOT choose treatment unless a gout attack has occurred
A
2
Q
Uric acid comes from breaking down __________
A
purines, often in foods and medications
3
Q
Gout is a type of arthritis caused by _______
A
a buildup of Uric acid crystals, primarily in the joints.
Uric acid crystallization
4
Q
Symptoms of Gout include:
A
Severe pain, swelling and redness in joints.
Sudden onset
5
Q
Uric acid is produced as an end product of ________
A
purine metabolism
6
Q
Uric acid is mainly excreted, _____
A
renally (primarily)
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
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.
9
Q
Gout typically occurs in one joint, most often the _______________
A
metatarsophalangeal joint (MTP, the big toe)
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
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
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
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
14
Q
Asymptomatic hyperuricemia is NOT ______
A
treated with drugs
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)
16
Q
The prophylactic drugs are used to lower (UA) Uric acid levels, with a goal UA level of______________
A
less than < 6mg/dL
17
Q
An acute gout flare can occur when ___________
A
an XOI is started, so give initially with colchicine or an NSAID
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
Colcrys
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Mitigare
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Gloperba
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Indocin
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Aleve
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Sulindac
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Intensol
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
prednisone
Class: Corticosteroid
Indications: acute gout flare
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
32
Rayos
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
prednisone
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
33
Millipred
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
prednisolone
34
Medrol
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosing: oral dose pack
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
35
Solu-Medrol
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
triamcinolone
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
37
Zyloprim
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Aloprim
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Uloric
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Zurampic
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Duzallo
allopurinol/lesinurad
42
Probenecid
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Krystexxa
cra-stex-za
Class:
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
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
Uric Acid Production and where Drug Treatment intervenes:
Adenosine ---> Hypoxanthine ---> Xanthine ---> Uric acid
