Gout

Question 1

presentation of gout

Answer 1

sudden 
extreme pain 
redness
systemic - fever and chills 
warmth

Question 2

modifiable risk factors

Answer 2

hyperuricemia 
hypertension
obesity 
diabetes
alcohol consumption 
high purine intake 
drugs

Question 3

non modifiable risk factors

Answer 3

CKD
male gender
age
family history

Question 4

hyperuruicemia uric acid levels in males

Answer 4

> 480umol/L

Question 5

hyperuricemia uric acid levels in females and why are they lower than males

Answer 5

> 420umol/L
estrogen promotes excretion of uric acid
after menopause closer to male levels

Question 6

uric acid production

Answer 6

breakdown of dna into purines that degrade into uric acid

Question 7

dietary sources

Answer 7

high protein meat
fish
beer

Question 8

causes of uric acid overproduction

Answer 8

diet - only plays a role if secondary metabolic problem
tissue breakdown
metabolic derangement
cancer blast cells have a high death rate do lots of dna being degraded

Question 9

causes of uric acid underexcretion

Answer 9

renal abnormalities

Question 10

why does poor kidney function affect uric acid levels

Answer 10

lots of movement in and out of the kidney

kidney excretes the uric acid

Question 11

why does gout occur in peripheral sites

Answer 11

solubility decreases as the temp of the tissue decreases

as get further from the body the temp is decreased

Question 12

things you need for gout to occur

Answer 12

high uric acid levels
colder temp of the body
joint that has been damaged in some way

Question 13

how fast does gout occur

Answer 13

over night

Question 14

how long for recovery if left untreated

Answer 14

3-14 days

Question 15

joint affected in gout

Answer 15

toe 
instep
ankle 
heel
knee
wrist
finger 
elbow

Question 16

precipitating factors for an attack

Answer 16

stress or trauma
alcohol 
infection 
surgery 
rapid lowering of serum uric acid****
drugs that increase uric acid

Question 17

issues with measuring serum uric acid level

Answer 17

will be normal bc the uric acid is redistributed into the joint and draws down the plasma level even tho its normally high

Question 18

labs to get

Answer 18

serum uric acid level
creatinine and BUN
if other sx present that may relate to cancer get a CBC

Question 19

chronic complications of gout

Answer 19

nephrolithiasis (uric acid stones in kidneys)
gouty nephropathy acute or chronic
tophi formation - fluid accumulation

Question 20

what is chronic tophaceous gout

Answer 20

chronic urate deposits in catilage, tendons, and synovial membranes
occur when intercritical periods no longer pain free
intermittent acute gout for 10 years

Question 21

treatment goals

Answer 21

relieve pain and inflammation within 48hrs of an attack
complete resolution of symptoms in 7 days
reduce uric acid levels to below 360umoléL
prevvent recurent attacks
prevent chronic complications

Question 22

drugs for acute gouty arthritis

Answer 22

nsaids
cox2 inhibitor
colchicine
corticosteroids

Question 23

short term prophylactic drugs

Answer 23

colchicine

nsaid low dose

Question 24

long term prophylactic drugs

Answer 24

allopurinol

febuxostat

Question 25

drugs that can cause hyperuricemia

Answer 25

``` diuretics (thiazide) salicylates theophylline glucocorticoids ketoconazole cyclosporin tacrolimus ```

Question 26

ibuprofen dose

Answer 26

600 QID

Question 27

naproxen dose

Answer 27

750 then 500 BID

Question 28

indomethacin dose

Answer 28

50 TID

Question 29

celceoxib dose

Answer 29

400 BID x 2days then 200 BID

Question 30

initiation and stoping for nsaids in acute flare

Answer 30

use max dose at first sign of attack lower dose as symptoms resolve leave on until joint pain has resolved totally for 48hrs (10 days )

Question 31

other prescriptions to give with nsaids

Answer 31

PPI for gut protection | more for next acute attack

Question 32

colchicine drug interactions

Answer 32

cyo 2A4 inhibitors: diltiazem, verapamil, itraconazole, fluconazole, clarithromycin statins and fibrates increase myalgia

Question 33

colchicine dosing acute flare

Answer 33

1.2mg followed by 0.6mg in one hour | if tkaing prophylaxis just stop during treatment and resume in 12 hours

Question 34

prednisone dosing acute

Answer 34

20-40mgéday for 4 days then taper over 1-2 weeks | pain relief in 12-48hrs

Question 35

how to determine whether to use prophylactic therapy

Answer 35

serum urate concentration after attack has resolved

Question 36

short term prophylaxis in patients with no tophi and normal or slightly elevated uric acid levels

Answer 36

colchicine 0.6mg BID | low dose NSAID

Question 37

when to stop short term prophylaxis

Answer 37

uric acid normal and patient symptoms free for 6 months

Question 38

when would you consider urate lowering therapy

Answer 38

recurrent attack, arthropathy, xray chages tophi gout with CKD recurring renal stones need for ongoing diuretic treatment after first attack

Question 39

BP lowering therapies to use instead of hydrochlorothiazide, beta blockers, ACEI

Answer 39

CCB | losartan

Question 40

goal of urate lowering therapy

Answer 40

<360umol/L

Question 41

allopurinol MOA

Answer 41

blocks conversion of hypoxanthine to xanthine then uric acid

Question 42

what is allopurinol hypersensitivity syndrome

Answer 42

isolated rash | severe cutaneous reactions, fever, eosinophilia, leukocytosis, renal involvement and hepatitis

Question 43

risk factors for allopurinol hypersensitivity syndromr

Answer 43

recent onset of therapu CKD thiazides

Question 44

initiating urate lowering therapy (prophylaxis)

Answer 44

start with rpophylactic therapy for the first 6 months colchicine 0.6mg BID if crcl>50 or low dose nsaid naproxen 250 BID

Question 45

when to start allopurinol

Answer 45

3 weeks after resolution of acute attack | initiat prophylactics 2 weeks before start

Question 46

dosing of allopurinol

Answer 46

``` 100mg OD (50 if <50crcl) titrate up 100mg every month until target of <360 dose beyond 300mg/day if needed ```

Question 47

do you dicontinue allopurinol in acute flares

Answer 47

no

Question 48

avoid combo of allopurinol or febuoxstat and

Answer 48

azathioprine 6 MP block thier secretion adn get serious toxicity

Question 49

febuxostat MOA

Answer 49

potent non purine selective inhibitor of xanthine oxidase

Question 50

febuxostat doseing

Answer 50

40mg daily titrate to 80mg after 2 weeks if serum >360 no dose adjustment in crcl>30 safe in moderate hepatic impaiement

Question 51

when would you use febuxostat

Answer 51

allergic to allopurinol | also continue prophylaxis for 6 months withthis

Question 52

non pharms

Answer 52

drink dairy? vit c? comfortable shoes reduce alcohol