Gout

Question 1

What’s gout?

Answer 1

Dz marked by monosodium urate/uric acid deposits in:

1. synovial fluids
2. tissues
3. kidneys

Question 2

T or F: It’s important to know whether a pt is an underexcreter or overproducer of uric acid.

Answer 2

F

Question 3

What is uric acid?

Answer 3

end product of purine metabolism

Question 4

What do Xanthine Oxidase (XO) inhibitors do?

Answer 4

They prevent the synthesis of uric acid from taking place by either blocking purine metabolism or purine metabolites from being converted into uric acid.

Question 5

Name the XO inhibitors:

Answer 5

1. allopurinol

2. febuxostat

Question 6

4 phases of gout:

Answer 6

1. asymptomatic hyperuricemia
2. acute gouty arthritis (flare)
3. intercritical gout
4. chronic tophaceous gout

Question 7

What’re tophi?

Answer 7

Uric acid deposits in tissues (e.g. joints, kidneys) > pain, damage, destruction can result

Question 8

During a gout workup, what score would indicate that a pt has gout?

Answer 8

> 7 (90% chance pt has gout)

Question 9

What uric acid level is considered hyperuricemia?

Answer 9

> 420 µmol/L

Question 10

Two types of gout drugs:

Answer 10

1. acute attack drugs

2. preventative drugs

Question 11

How long do acute gout flares last?

Answer 11

7-14 days

Question 12

Most likely joints to be affected by gout flares?

Answer 12

peripheral, smaller joints

Question 13

1st line drug for gout flares?

Answer 13

NSAIDs (except ASA)

Question 14

How to use NSAIDs during gout flares?

Answer 14

High initial dosing for 24-72h, followed by lowest effective maintenance dosing (total tx period = 7d)

Question 15

T or F: NSAIDs are more effective than CS’s and colchicine when it comes to tx’ing acute gout flares.

Answer 15

F

They all have similar efficacies

Question 16

Why is ASA avoided in tx’ing gout flares?

Answer 16

bc it reduces uric acid excretion in the kidneys

Question 17

Drugs used to tx gout flares:

Answer 17

1. NSAIDs (save for ASA)
2. CS’s (oral, intra-articular, or parenteral)
3. Colchicine

Question 18

MOA of colchicine?

Answer 18

Prevents uric acid from getting into joint space

Question 19

What should colchicine be started?

Answer 19

Within 24h of flare

Question 20

Least tolerated acute flare tx?

Answer 20

Colchicine (N/V/D, fatigue, myopathy, blood abnormalities)

Question 21

When should gout flare combo tx be utilized?

Answer 21

Severe flares or if monotx isn’t working.

Question 22

Acceptable combo tx’s for gout flares?

Answer 22

1. Colchicine + NSAID
2. Colchicine + CS
3. intra-articular CS + NSAID OR oral steroid OR colchicine

(avoid NSAID + oral CS > increases GI AEs and not much benefit)

Question 23

Serum urate goal for gout prophylaxis?

Answer 23

<360 µmol/L

Question 24

What is the purpose of colchicine + NSAIDs in gout prophylaxis?

Answer 24

To prevent flares during initiation of other prophylactic drugs.

Question 25

Drugs used in gout prophylaxis:

Answer 25

1. Colchicine + NSAIDs
2. Xanthine oxidase inhibitors (allopurinol, febuxostat)
3. uricosuric agents (probenecid, sulfinpyrazone)
4. uricase enzyme (pegloticase, rasburicase)

Question 26

Major allopurinol AE?

Answer 26

Allopurinol hypersensitivity syndrome

Question 27

Allopurinol hypersensitivity syndrome - what should the pt look out for?

Answer 27

A rash

Question 28

First line for gout prophylaxis?

Answer 28

Allopurinol

Question 29

What if pt can’t tolerate allopurinol?

Answer 29

Tx with febuxostat

Question 30

Why should we slowly titrate allopurinol up rather than just start on a higher dose from the start?

Answer 30

To avoid allopurinol hypersensitivity syndrome

Question 31

What do uricosuric agents do?

Answer 31

Increase renal Cl of uric acid

Question 32

What kind of patient would benefit from uricosuric agents?

Answer 32

Underexcreters only (only time when knowing whether a pt is an underexcreter or overproducer is useful)

Question 33

When is uricase enzyme tx used?

Answer 33

When it’s severe gout and other options have failed

Question 34

Common AE with uricase enzyme tx?

Answer 34

Ab development > decreased efficacy

Question 35

Safe drugs for ACUTE FLARES during pregnancy?

Answer 35

1. colchicine

2. short courses of prednisone

Question 36

Safe drugs for PROPHYLAXIS during pregnancy?

Answer 36

allopurinol

Question 37

Safe drugs for PROPHYLAXIS during lactation?

Answer 37

1. ibuprofen
2. prednisone
3. allopurinol