Gout

Question 1

Describe gout progression

Answer 1

Asymptomatic hyperuricemia
Acute gout
Intercritical gout (no symptoms) - could go backwards
Chronic/tophaceous gout

Question 2

What levels do we want to keep uric acid levels? Why?

Answer 2

Below 6

At 6.8 it precipitates in solutions

Question 3

How is uric acid eliminated?

Answer 3

98% of filtered load is recovered in the urine

Important to keep kidneys functioning well

Question 4

What risk factors are there for gout?

Answer 4

Males between 20-40
Post menopausal women
Low dose ASA, nicotinic acid, B-blockers, chemotherapeutic agents
Patients on diuretics (increases reabsorption of uric acid in the kidneys) - thiazides and loops, not K/Mg sparing
Patients with HTN, DM, Hyperlipidemia, CKD, or Metabolic syndrome

Question 5

Whats the difference between gout and pseudogout?

Answer 5

Under microscope, uric acid crystals look like needles

Calcium oxalate crystals look like boxes, this is pseudogou

Question 6

How is acute gout treated?

Answer 6

NSAID’s first choice
Colchicine if contraindicated to NSAID

If inadequate for both of those, use either injection of corticosteroid or parenteral/oral corticosteroid (if more than one joint affected)

Question 7

When should NSAID’s be used cautiously or avoided?

Answer 7

CrCL less than 50

Peptic ulcers, hepatic dysfunction, heart failure, and anticoagulation therapy

Question 8

When starting NSAID treatment, what should be monitored?

Answer 8

SCr
Blood pressure
Electrolytes

Question 9

What is the best NSAID to start with? Worst?

Answer 9

Ibuprofen and Sulindac the best

Indomethacin don’t start bc they were most likely to induce renal toxicity

Can also use naproxen oral or ketorolac but ketorolac has increased bleeding risk and is IV/IM only

Question 10

What did the AGREE trial tell us?

Answer 10

Colchicine lower doses equally effective as high doses with less side effects

So start colchicine at low dose and increase as needed

Question 11

What drug interactions do you worry about with colchicine?

Answer 11

Erythromycin
Several statins
H2 blockers
Ketoconazole topical

Question 12

When do we use prednisone?

Answer 12

Use prednisone 40-60 mg daily for 5-7 days then taper 1-2 weeks (oral) if more than one joint affected

Use in pts who cannot tolerate NSAIDs or who failed NSAID/colchicine therapy

Question 13

When do we use injectable steroids?

Answer 13

When one joint is infected or it’s a larger joint

Use methylprednosone 5-25 mg per joint, triamcinolone (knee joint 10 mg small joints 8 mg)

Question 14

What is the treatment goal for chronic gout?

Answer 14

Lower uric acid levels to below 357 micromole per liter (6mg/dL)

Question 15

Can you give chronic gout drugs during an acute attack?

Answer 15

NO - could cause flairs to move from one joint to multiple joints “Mobilization flairs”

Give 1-2 weeks AFTER acute attack has subsided

Question 16

When do we consider urate-lowering therapy?

Answer 16

Considered in uncomplicated gout if second attack or further attacks occur within 1 year

Question 17

What is the agent of choice to lower serum uric acid?

Answer 17

Allopurinol - blocks uric acid synthesis

Question 18

Dosing for allopurinol

Answer 18

Start at 100 mg/day then go up 100mg/day every 1-4 weeks until target serum uric acid is achieved (usually 300 mg/day)

Dose response flattens out around 500 mg/day

Renal insufficiency (CrCL less than 60: start at 50 mg/day and go up)

CrCL 10-20 max 200 mg/day
CrCL less than 10 max 100 mg/day

Question 19

Side effects of allopurinol?

Answer 19

HYPERSENSITIVITY RXN - rash!!! High mortality
Test for antigen in Koreans with stage 3 CKD, Han Chinese, and Thai

Highest risk at 1st 6-8 weeks of therapy

Question 20

What do we use if a pt has an allopurinol hypersensitivity reaction?

Answer 20

Febuxostat

Question 21

Dosing for febuxostat

Answer 21

40-80mg/day

No dosage requirement for renal or hepatic impairment

Question 22

Why not just use febuxostat instead of allopurinol?

Answer 22

Unclear if it offers more effective control
It is significantly more expensive

Stick to just using it with allopurinol hypersensitivity and intolerance or treatment failure

Question 23

Side effects of febuxostat?

Answer 23

Could have 3-5% elevation in LFT’s

Question 24

What are the uricosurics? When do we use them?

Answer 24

Probenecid, Sulfinpyrazone
Use them ONLY in younger patients (under 60), that are UNDER excretors, do NOT have reduced renal function (CrCL less than 60), or history of kidney stones, and do not require ASA or diuretic therapy

Question 25

What is pegloticase?

Answer 25

It is the enzyme that breaks down uric acid to allantoin - animals have it but we don't Use ONLY when other agents have failed

Question 26

When do we use Lesinurad?

Answer 26

Added on to xanthine oxidase inhibitors when they haven't achieved target sUA levels on xanthine oxidase inhibitor alone AVOID in pts with CrCL less than 45 mL/min (Used with allopurinol)

Question 27

How should NSAIDs be used to treat acute gout?

Answer 27

Highest dose for 2-3 days, then decrease over approximately 2 weeks Continue using nSAIDs for at least 48 hours after the resolution of symptoms Use NSAIDs cautiously in pts with CrCL less than 50 Start within 12-24 hours of acute attack

Question 28

AG is a 54 year old male who was recently diagnosed with acute gout. He asks you for a recommendation regarding the use of an NSAID to manage the pain associated with the attack. Which of the following is the BEST recommendation? A: NSAIDs should be started within 2-3 days of the acute attack for maximum benefit B: Start NSAIDs at the highest dose for 12 hours then decrease gradually over 5 days C: Continue NSAIDs for at least 48 hours after resolution of the symptoms D: Use NSAIDs cautiously in patients with CrCl

Answer 28

C: Continue NSAIDs for at least 48 hours after resolution of the symptoms

Question 29

AG is a 54 year old male who was recently diagnosed with acute gout. AG received significant relief from his acute NSAID and is now past the acute attack phase of his gout. His PCP decides to initiate chronic gout therapy and decides to start with allopurinol. The PCP measured AG’s renal function and found that his eGFR is 55 mL/min. The PCP asks you for a recommendation regarding allopurinol. Which of the following is the BEST response? A: Starting dose of allopurinol should be 50-100 mg/day B: Serum uric acid should be measured weekly until target level is achieved C: If AG’s CrCl drops to 10-20 mL/min, his maximum dose/day should not exceed 100 mg D: If AG’s CrCl drops to under 10 mL/min, allopurinol is contraindicated

Answer 29

A: Starting dose of allopurinol should be 50-100 mg/day Note: Normally start at 100 but bc he has CrCL less than 60 he should start 50-100 Levels should be measured monthly not weekly

Question 30

AG is a 54 year old male who was recently diagnosed with acute gout. AG’s primary care provider (PCP) just informed you that AG was recently diagnosed with hypertension. The PCP seems to remember from his residency that there might be an anti-hypertensive that could benefit patients with gout. He asks you for your input. What is your BEST response? A: Candesartan B: Losartan C: Valsartan D: Fenofibrate

Answer 30

B: Losartan