Gout Flashcards
(91 cards)
0
Q
tophi definition
A
aggregate deposits of sodium urate
1
Q
hyperuricemia serum uric acid concentraitons
A
6.8 or > 7
2
Q
renal manifestations of gout
A
urolithiasis
nephrolithiasis
3
Q
what is gout
A
recurrent attacks of acute arthritis caused by deposits of monosodium urate crystals in tissues in and around joints
4
Q
Risk factors for gout
A
purine rich foods medications coniditions associated with hyperuricemia age > 50 male increased body weight impaired renal function chemotherapy elevated serum uric acid levels
5
Q
medications that cause gout
A
thiazide diuretics niacin pyrazinamide cyclosporine and ASA
6
Q
conditions that are associated with high uric acid
A
HTN
dyslipidemia
Type 2 DM
coronary artery disease
7
Q
gout attacks during chemotherapy are called
A
tumor lysis syndome
8
Q
eliminate or uric acid
A
primarily urinary
9
Q
what is urate
A
end product of purine degradation with no physiological purpose
10
Q
What causes symptoms of gout
A
phagocytosis or urate crystals by luekocytes in the joint due to rapid lysis of cells and discharge of lysosomal and proteolytic enzymes into the cytoplasm
11
Q
most commonly affected joints
A
metatarsophalageal and knee joints
12
Q
symptoms of gout
A
severe pain swelling warmth monoarticular redness of joint \+/- mild fever tophi (chronic severe disease) rapid onset usually at night
13
Q
What tests to diagnose gout
A
joint fluid aspiration joint radiographs serum uric acid levels peripheral WBCs ESR 24 urine excretion
14
Q
joint fluid aspiration shows what in gout
A
monosodium urate crystals
WBCs (neutrophils predominate)
15
Q
Joint radiographs in gout
A
cystic changes
punched out lytic lesions with overhanging bony edges
soft tissue calcified masses
16
Q
serum uric acid levels in gout
A
can be normal or elevated during an attack
17
Q
24 urine exretion shows > 800 mg after a purine free diet
A
overproducer
18
Q
urine uric acid shows <600mg after a purine free diet
A
underexcretion
19
Q
urine uric acid shows >1000mg after a regular diet
A
overproducer
20
Q
Goals of treatment of gout
A
achieve rapid and effective pain relief Maintin joint function prevent disease complications avoid treatment AEs Provide cost effective therapy Improve QOL
21
Q
Non pharm treatment for gout
A
joint rest 1-2 days with ice
weight loss
diet, health, and lifestyle recommendations
22
Q
Nsaids FDA approved for acute gout attacks
A
Naproxen
Indomethacin
Sulindac
23
Q
Dose of Naproxen for gout
A
1000 mg QD x 3 days, 500 mg X 7d or 750 mg now, then 250 mg Q8H
24
Indomethacin dose for gout
150-200 mg qd (3 divided doses) X 3 days, then 100 mg QD for 4-7 days
25
sulindac dose for gout
200 mg BID x 7-10 days
26
avoid NSAIDS in who
```
peptic ulcer or risk
warfarin
renal insufficiency
uncontrolled hypertension
heart failure
```
27
acute attack dose of colchicine
1.2 mg X 1 dose, then 0.6 mg in one hour
28
Prophylactic dose of colchicine
0.6 mg 1-2 times daily
29
colchicine brand name
colcrys
30
What is the time frame for giving colchicine for an acute attack
36 hours
31
what is the time frame for giving NSAIDs for an acute attack
within 24 hours
32
AEs of colchicine
diarrhea, N/V, abdominal pain
| myopathy, neutropenia, alopecia (long term use), bone marrow suppression
33
Dose adjust colchicine in renal impairment
yes
34
reduce prophylactic dose of colchicine in who
age 70+
35
CIs for colchicine
PGP or 3A4 inhibitors in the prescence of hepatic or renal impairment
36
Avoid using colchicine with what
macrolides (clarithromycin)
37
Colchicine should be reserved for who
at risk for NSAID induced gastropathy
| NSAID therapy failures
38
oral treatment dosage of prednisone for gout
0.5 mg/kg/day x 5-10 days at full dose then stop or 205 days at full dose then taper for 7-10 days
39
Intrarticular treatment with corticosteroids considered when
know which joints involved, 1-2 joints involved
40
corticosteroids used for gout in which pt population
CKD patients - NSAIDs not great, colchicine clearance reduce
41
Intramuscular treatment of corticosteroids dose
Triamcinolone 60 mg, then oral prednisone
42
AEs of corticosteroids
Increase glucose levels, fluid retention, impaired wound healing, weight gain, CNS stimulation, increased infection risk
43
Cautions with corticosteroids
Diabetes, patients who joint sepsis cannot be excluded, psychiatric disorders, cardiovascular disease
44
Why avoid long term corticosteroids
risk for osteoporosis, adrenal suppression, cataracts, muscle deconditioning
45
Treat or not with asymptomatic hyperuricemia
not usually unless indication for urate lowering therapy
46
indications for urate lowering therapy in asymptomatic hyperuricemia
tophus or tophi by clinical exam or imaging study
2+ attacks per year
CKD stage 2 or worse
uric acid nephrolithiasis
47
Goal serum urate level
<6 mg/dL, may need lower for symptomatic improvement
48
Xanthine Oxidase Inhibitors
Allopurinol
| Febuxostat
49
are xanthine oxidase inhibitors good for overproducers or underexcretors?
BOTH!
50
xanthine oxidase inhibitor MOA
blocks xanthine oxidase resulting in decrease uric acid production
51
Allopurinol initial dose
100 mg QD titrate up Q2-5 weeks until goal uric acid (max dose max 800 mg /day
52
allopurinol initial dose in stage 4 or worse CKD
50 mg/day
53
monitor serum uric acid when after starting allopurinol
1 week
54
AEs of allopurinol
dose dependent skin rash
GI intolerance
headache
allopurinol hypersensitivity syndrome
55
allopurinol hypersensitivity syndrome symptoms
```
stevens johnson syndrome
toxic epidermal necrolysis
eosinophilia
vasculitis
rash
end-organ disease
```
56
high risk populations for allopurinol hypersensitivity syndome
korean with stage 3 or worse CKD
| han chinese or thai
57
feboxostat brand name
uloric
58
dose of febuxostat
40 mg qd; increase to 8 if not at goal after 2 weeks
59
dose adjust febuxostat in renal impairment
nope
60
monitoring for febuxostat
baseline LFT, 2+4 months, periodically
61
AEs of febuxostat
diarrhea, rash, pharyngolaryngral pain
blood dyscrasias
arthritis
nausea
62
caution with febuxostat
possible CV thrombotic events and increased liver enzyme
63
CIs with febuxostat
use with azathioprine, mercaptopurine, or theophylline
64
uricosuric drugs
probenecid
fenofibrate
losartan
sulfinpyrazone
65
uricosuric drugs for who
underexcretors!
66
uricosuric drugs MOA
increases renal excretion of uric acid by decreasing uric acid reabsorption in the renal tubules
67
AEs of uricosuric drugs
GI irritation
Rash and hypersensitivity
precipitation of acute gouty arthritis
stone formation
68
CIs of uricosuric drugs
```
hypersensitive pts
impaired renal function <50 ml/min
history of renal calculi
overproducers of uric acid
history of urolithiasis
```
69
Probenecid dosing for gout
250 mg BID x 1-2 weeks, then 500 mg BID x 2 weeks, max 1000 mg BID
70
Drug interactions with uricosuric drugs
salicylates (<325 mg enteric coated ok)
71
Probenecid drug interactions
increases concentration of penicillin, cephalosporin, sulfonamides, and indomethacin
72
When to discontinue chronic treatment of gout
Pt w/o evidence of tophi
6-12 months after normal levels of urate are reached
consider adherence
73
foods to avoid in gout
purine rich organ meats
high fructose corn syrup
alcohol overuse (>2 per men, >1 women)
any alcohol during gout attacks or poorly controlled gout
74
foods to limit in gout
```
beef, lamb, pork
high purine seafood
fruit juices
sugar and sweetened things
table salt (sauces and gravy)
```
75
Foods to enourage in gout
low fat or non-fat dairy
| vegetables
76
first line for gout with no peptic ulcer risk and CrCl >30
NSAIDS
77
second line with no peptic ulcer risk and CrCl > 30 for gout
Colchicine
78
option for monoarticular gout with no peptic ulcer risk and CrCl > 30
intrarticular corticosteroid
79
First line for gout attack if CrCl < 30
systemic corticosteroid
80
first line for gout attack with peptic ulcer risk
colchicine
81
when after acute gout treatment do you determine the need for prophylaxis
4-6 weeks
82
First line if prophylaxis is needed with renal insufficiency +/- uric acid stones with CrCl > 30
febuxostat
83
first line if prophylaxis needed with renal insufficiency +/- uric acid stone and CrCl < 30
allopurinol
84
Prophylaxis is needed with no renal involvement
allopurinol, febuxostat if not tolerated or goal not reached
85
colchicine dose in CrCl < 30
0.3 mg QD
86
colchicine dose on dialysis
0.3 mg twice weekly
87
colchicine dose for adults 70+
reduce dose by 50%
88
max allopurinol dose in CrCl 10-20
200 mg/day
89
max allopurinol dose in CrCl 3-10
100 mg/day
90
allopurinol dose for CrCl <3
100 mg with extended dosing intervals
