gout Flashcards by kehgan Sam

where does Gout typically occur and what causes it?

Typically occurs in the metatarsophalangeal joint (MTP, big toe) and is due to many years of persistent hyperuricemia.

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Risk Factors for gout

-Male sex, Overweight, Excessive alcohol intake (beer), Hypertension, Renal insufficiency, Advanced age, Medication (Diuretics, niacin, aspirin, and pyrazinamide

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Treatment Goals for gout

Treat acute attacks, Prevent future flare-ups, Reduce UA levels

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What are the first line agents for Acute Gout Attack Treatments

-Colchicine (Colcrys); NSAIDS: Indomethacin (Indocin), Naproxen (Naprosyn), Sulindac (Clinoril),Celecoxib (Celebrex); Steroids:Prednisone, Methylprednisolone, Triamcinolone

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Colchicine (Colcrys) moa

Inhibits beta-tubulin polymerization

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Administration directions for Colcrys initiation

-At first sign of attack take 2 tablets (1.2mg) followed by 1 more tablet (0.6mg) in one hour (max = 1.8 mg/day);

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NSAIDs used in Gout & when should they be avoided?

-Indomethacin (Indocin), Naproxen (Naprosyn), Sulindac (Clinoril), Celecoxib (Celebrex); Avoid use in severe renal disease

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What are the side effects of indomethacin

psychiatric: confusion, depression, psychosis

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What dose of Naproxen is used in gout & for how long

750mg once, then 250mg q8h until attack resolves

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What is the dose of Indocin for gout

50mg, TID till attack resolves

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For gout, what are the routs of administration of steroids?

PO, IM, IV, intra-articular or ACTH( adrenocorticotropic hormones)

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what are the acute side effects of steroids

Side effects: increased blood glucose, elevated blood pressure, nervousness, insomnia, increased appetite, and edema

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which steroids are used intra-articularly for gout

Methylprednisolone and triamcinolone is given intra-articularly based on joint size

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Which medications can be used for Prophylactic Treatment (lowering of uric acid production)

Allopurinol (Zyloprim), Febuxostat (Uloric), Probenecid, Pegloticase (Krystexxa)

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Prior to initiation of UA-lowring therapy what should the patient do?

take colchicum 0.6mge daily or BID or NSAIDs for at least 6 months to reduce acute flares

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What are Xanthine oxidase inhibitors and how doe they work

Allopurinol(Zyloprim) & Febuxostat(Uloric); MOA: block UA prodution

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Side effects of Allopurinol (Zyloprim) & renal adjustment

Side effects: precipitation of gout attacks, increase LFTs, and skin rash; Dose adjust if CrCl <20

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What are the warning for Zyloprim (allopurinol

Hypersensitivity: test HLAB*5801 prior to start, hepatotoxicity

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What is the initial dose of allopurinol

50-100mg/day; slowly titrate to UA target; doses >300mg needed in pts w/ CKD

Couseling for Allopurinol

take once daily with a meal to Reduce stomach upset, May take up to several weeks for medicine to be effective, If you get a rash, notify your doctor

Febuxostat (Uloric) is ideal for whom and why?

For resistant cases b/c it is very expensive, and possibly in renal disease as no dose adjustment needs to be made

What are the contraindications to Uloric use

concurrent use with azathiopurine or mercaptopurine

What are the side effects & warnings of Uloric

-Side effects: liver enzyme elevation, rash; Warning: Hepatotoxicity(eps in liver impairment) increased thrombocytopenic events

Probenecid MOA & indication

-Uricosuric: Inhibits the reabsorption of uric acid; indicated when XO inhibitors are CI, not tolerated or added if UA level not at goal w/ max dose of XO-inhibitor

What interactions does probenecid have

may decrease renal clearance of (aspirin, methotrexate, theophylline, penicillins)

What are the contraindications to probenecid?

Concomitant use of aspirin; uric acid kidney stones; blood dyscrasias, starting during an acute attack, CrCl <30ml/min

What are the side effects & warnings of Probenecid?

Side effect: hypersensitivity rtxn, hemolytic anemia; Warning: increased risk hemolytic anemia in G6PD deficient pts

pts on uricosurics must have what?

good renal function. if pt's CrCl <50, this can not be used mono therapy

Pegloticase (Krystexxa) class and MOA

recombinant Uricase enzyme: converts uric acid to an inactive water-soluble metabolite that can be easily excreted.

In what cases is pegloticase (Krystexxa) indicated for use?

Used in resistant cases only

What are the side effects of pegloticase (Krystexxa)

Antibody formation, gout flare, infusion rxtn, urticaria, erythema, pruritus, bruising

Pegloticase (Krystexxa) is never to be used in combination with which gout agent?

allopurinol

Pegloticase BBW, how is it managed & who is at risk

Anaphylactic rxtn: during infusion; premeditate with antihistamines & steroids; highest risk if UA level >6mg/dl (D/C) therapy

Krystexxa (pegloticase) is contraindicated in which condition

G6PD deficiency

do not use X for acute treatment

ASPIRIN (bufferin included in this)

food to avoid

organ meats, high fructose corn syrup & alcohol, fruit juice, table sugar, sweetened drinks, salt, beef, seafood )high in purine sward fish, shellfish)

what is the normal serum uric acid level

-Normal serum uric acid levels: 2.0 - 7.2

How is uric acid produced

Uric acid is produced as an end-product of purine metabolism

What are the side effects & warnings of Colchicine (Colcrys)

Side effects: nausea, vomiting, abdominal pain, diarrhea; Warning: decreased clearance in renal & hepatic impairment

What interactions does Colcrys have & how are they managed?

interacts with 3A4 inhibitors (clarithromycin) and P-gp inhibitors (cyclosporine); a max dose of 1.2mg (2 tablets) can be used acutely if using these agents

how many days should a patient wait before starting another course of therapy

Wait at least 3 days before initiating another course of therapy

When is the second dose of colchicine not given

-You should not take the 2nd dose if you have upset stomach, nausea, and diarrhea

What is the prophylactic dose of colchicine

0.6mg BID starting 12 hours after acute dosing & continued till attack resolves

Colchicine is contraindicate if

pt is taking P-gp or strong CYP 3A4 inhibitor & they have renal or liver impairment

When is the ideal colcrys initiation time?

within 36 hours of onset & only if pt has not used it prophylacticly & used acute regimen in the last 14 days

Medications known to increase Uric acid

Diuretics( thiazides & loops), niacin, aspirin (higher doses), pyrazinamide, cyclosproin, tacrolimus

What is the target Uric acid level for chronic therapy with XO-inhibitors

<5-6mg/dl