Gout Flashcards
(105 cards)
1
Q
Which patient group are likely affected by gout
A
Older adults
Obese adults
Male
2
Q
What is gout
A
Overproduction or underexcretion of Uric acid
3
Q
What is considered hyperuricemia for male and female
A
Male serum urate > 7 mg/dL
Female serum urate > 6 mg/dL
4
Q
What is the pathophysiology for gout
A
Hyperuricemia
Deposition of monosodium urate crystals causing inflammation
Development of tophi
Nephrolithiasis, nephropathy (kidney stone or damage)
5
Q
What are the medication that increase serum urate/hyperuricemia
A
Thiazides
Cytotoxic agents
Cyclosporine
Niacin
Low-dose aspirin
6
Q
Acute gout affects how many joint
A
Monoanticular usually the big toe joint
7
Q
What are the sx of acute gout
A
Joint pain, erythema, swelling, warmth
8
Q
Atypical presentation of acute gout is seen in which patient group and is sometimes confused with what pathology
A
Elderly patients
RA or OA
9
Q
What type of gout is known as podagra
A
Classic gout
10
Q
How is acute gout assessed
A
Sx and hx
Aspiration of synovial fluid to identify crystals
Serum uric and: which can be low or normal
Radiograph
11
Q
The 2020 American college of rheumatology guideline classifies the management of gout under what two categories
A
Strong
Conditional
12
Q
What is the strong recommendation for acute gout management
A
Low dose colchicine
NSAIDs
Glucocorticoids
13
Q
What are the conditional recommendation for acute gout management
A
Topical ice
IL-1 inhibitor when all else fails
14
Q
A gout pain scale of ≤4 is considered
A
Mild
15
Q
A gout pain scale of 5-6 is considered
A
Moderate
16
Q
A gout pain scale of ≥ 7 is considered
A
Severe
17
Q
A duration of a gout attack since < 12hours after onset is considered
A
Early
18
Q
A duration of a gout attack since 12-36 hours after onset is considered
A
Well-Established
19
Q
A duration of gout attack > 36 hours since onset is considered
A
Late
20
Q
How is the extent of gout attack classified
A
Based on number of joints affected
21
Q
Extent of gout attack classifications
A
One or a few small joint
1 or 2 large joints (ankle, knee, wrist, elbow, hip, shoulder)
Polyarticular ( 4 or more joints involving more than one region or 3 separate large joint )
22
Q
Acute gout attacks should be treated with what?
A
Pharmacologic therapy
23
Q
To provide optimal care, pharmacologic therapy should be initiated when
A
With 24 hours of onset
24
Q
Should ongoing Uric lowering therapy be interrupted during an acute gout attack
A
No
25
What is the first thing when managing acute gout attacks
Assess severity
26
If severity is mild or moderate pain involving 1 or 2 small or large joint what should be initiated
Monotherapy and supplement with topical ice if needed
27
What are the monotherapy
Colchicine
Systemic corticosteroids
NSAIDs or cox-inhibitors
28
What if assessing severity pain is severe involving polyarticular or multiple large joints what kind of therapy should be initiated
Initial combination therapy
29
What if after initiating monotherapy there is inadequate response what should you do
Consider alternate monotherapy
or
Try add-on combination therapy
30
What if after switching to a different monotherapies or trying add-on combination there is still inadequate response what should you do?
Consider off-label therapies in development
31
What is meant by inadequate response
< 20% improvement in pain score within < 24 hours of therapy initiation
Or
< 50% pain reduction at ≥ 24 hours of therapy initiation
32
What do you when patient is reporting well to monotherapies
Initiate patient education on:
Diet and lifestyle triggers and role of prompt self-treatment of subsequent attacks
Consider indications for ULT or adjustment of ongoing ULT treatment
33
What NSAIDs are considered for acute gout attacks
Naproxen
Indomethacin
Sulindac
34
What is the duration of therapy with NSAIDs
5-7 days
35
How is naproxen dosed for acute gout attacks
750 mg initially then 250mg every 8hours
36
How is indomethacin dosed for acute gout attacks
50 mg TID
37
How is sulindac dosed for acute gout attacks
200 mg BID
38
When using NSAIDs as therapies what should you be mindful of
GERD, GI events or Hypertension
39
What is first line recommendation
Colchicine
40
Colchicine MOA
Inhibits polymerization of beta-tubulin into microtubule prevention activation and migration of neutrophils
41
When is colchicine initiated
Within 36 hours of sx onset
42
For whom should dose be adjusted for and contraindicated
Renal/hepatic impairment
P-gp or CYP3A4 inhibitors
43
What are the ADRs of colchicine
GI
Myopathy
Myelosuppression
44
How is colchicine dosed
1.2 mg followed by 0.6mg 1 hour later
45
If a patient is having a gout attack but have never been on colchine prophylaxis
Or
Has not received colchicine within the last 14 days what should be done
Start 1.2mg followed by 0.6 mg an hour later and start prophylaxis dosing at 12 hours or later until gout resolves.
46
What if your patient has received colchience within the last 14 days and is having acute gout attack what should be done
Choose NSAID or corticosteroid
47
if patient is on NPO what corticosteroid dosage form should be used
IV, IM or IA
48
For acute gout affecting 1-2 larger joints how is corticosteroids used
Consider intra-Articular corticosteroids
49
For all cases of gout how is corticosteroids initiated
0.5mg/kg of prednisone perday for 5-10 days at full dose
Or
2-5 days at full dose and gradually taper off for 7-10 days and stop
Or
Methylprednisolone dose pack
50
How is intramuscular corticosteroid dosed for acute your
Triamcinolone 60 mg followed by oral prednisone
51
When gout attack is considered severe or patient is considered inadequate response to monotherapy what is the approved combination therapy that can be initiated
Colchicine + NSAIDs
Oral corticosteroids + colchicine
Intrarticular steroid + any other systemic options
52
What combination therapy should be avoided
NSAID + systemic corticosteroid due to GI toxicity
53
Off label IL-1 inhibitors
Anakinra
Canakinumab
54
Off-label herbal
Cherries extract
Dairy protein
55
What lifestyle management can be used for chronic management of gout symptoms
Limit alcohol intake
Limit purine intake
Limit high fructose com syrup intake
Loose weight of obese or overweight
Do not use vitamin C supplementation
56
When is pharmacologic ULT strongly recommended for chronic management of gout
≥ 1 subcutaneous tophi
Radiography damage attributed to gout
Frequent gout flares
57
When is pharmacologic ULT conditionally recommended for chronic management of gout
> 1 flare but have infrequent flare
Or
First flare with:
Moderate to severe CKD
Serum Urate > 9 mg/dl
Urolithiasis (kidney stone)
58
Pharmacologic ULT is conditionally recommended against for
First gout flare
Asymptomatic hyperuricemia
59
What are the ULT
Allopurinol
Febuxostat
Probenecid
Leisured
Pegloticase
60
Which ULT’s are Xanthine oxidase inhibitors
Allopurinol
Febuxostat
61
Which UTL’s are uricosuric agents
Probenecid
Lesinurad
62
What is first line ULT
Allopurinol
63
What test should select population (South-Asian, African American) do to identify risk of developing serious side effects of
HLA-B*5801
64
What is the daily starting dose of allopurinol
≤ 100 mg
65
For Patient with CKD or worse renal function what is the starting allopurinol dose
50 mg
66
Allopurinol ADR
Rash
Pruritus
Allopurinol hypersensitivity syndrome
Elevated hepatic transaminases
67
Can > 300 mg be used in renal impairment if accompanied by patient education and monitoring
Yes
68
Febuxostat initial dosing
40 mg once daily
69
Caution when dosing febuxostant
Severe renal/hepatic impairment
Previous allopurinol hypersensitivity
70
Who is febuxostat contraindicated (BBW) and why
Cardiovascular disease due to increased risk of death
71
Febuxostat ADR
Rash,
liver function abnormalities,
nausea,
arthralgia,
hypersensitivity,
gout flare
72
Probenecid MOA
Inhibit reabsorption of uric acid from PCT
73
Probenecid contraindication
Urolithiasis History
74
Probenecid initial dosing
250mg BID for a week then 500 mg BID
75
For which patient is probenecid not recommended as first line
CrCl < 50ml/min
76
Probenecid ADR
Urolithiasis
GI upset
77
Pegloticase MOA
Pegylated recombinant uricase that converts Uric acid to allantoin
78
When is pegloticase used
In severe disease. never first line of therapy
79
Dosage Form of pegloticase
IV only
80
What should be done before pegloticase administration
Pretreat with antihistamine or corticosteroids
81
Pegloticase dosing
8 mg IV every 2 weeks
82
Contradiction for pegloticase
G6PD deficiency
83
Pegloticase ADR
Anaphylaxis
Infusion reaction
84
What is the con of pegloticase
Infusion takes > 2 hours
Cost
Infusion related reactions
85
What are the two miscellaneous Urate lowering agents
Fenofibrate
Losartan
86
How does fenofibrate help with gout
Increasing clearance of hypoxanthine and xanthine
87
During the initiation of fenofibrate did patient indicate gout flare
No
88
What about fenofibrate is conditionally recommended against
Addition or switching as risks outweigh potential benefit
89
How does losartan help with gout
By inhibiting renal reabsorption of uric acid and increasing its excretion and alkalanizing urine
90
Why is losartan unique with this application
Its mechanism of action is not an ARB class effect
91
When is losartan conditionally recommended
To use when feasible
92
During the initiation of a ULT was is the target serum uric acid level
< 6 mg/dL
93
What is Strongly Recommended during initiation of ULT
First line allopurinol
CKD stage >3 start low dose XOI therapy
94
What is conditionally recommended during initiation of ULT
Low dose probenecid during gout flare instead of after resolution
95
During initiation of ULT what is Strongly Recommended against
Using pegloticase as first line therapy
96
During initiation of ULT what is strongly recommended as prophylaxis
Concomitant administration of either colchicine, NSAID, prednisone continued for 3-6 months
97
In management of ULT what general consideration is conditionally recommended
Intervention led by nurses or pharmacist should be included
ULT use can be continued indefinitely
98
When considering switching to alternate therapy what is conditionally recommended
It is conditionally recommended to Switch to different XOI if:
Serum Uric acid is persistently high
Continued frequent gout flare in greater than 2 years
Unresolved subcutaneous tophi
99
When considering switching to alternate therapy what is strongly recommended against
It is Strongly Recommended against switching patient to pegloticase for whom other ULT has failed but have infrequent gout flare in less than two years with no tophi
100
What are the steps to performing switches or making changes to gout therapy management
Before any switch as made, titrate x01 formaxionum appropriate close and measure uric acid every 2-5 weeks during titration
If not at goal add uricosuric to XOI titrating both at maximum appropriate dose
Last alternative is pegloticase use
101
If patient is at goal, how often should serum Uric acid be monitored
Every 6 months
102
What is colchicine drug interactions
CYP3A4 inhibitors
PGP inhibitors.
103
What is the interaction of allopurinol and febuxostat
They increase the concentration of warfarin, theophylline, azathioprine
104
What is the drug interaction with probenecid
Low dose aspirin decreases its urocosuric effect
It inhibits the tubular secretion of penicillin, cephalosporin, rifampin, methotrexate
105
Patient centered care focuses on what aspects
Renal insufficiency
GI disease
Congestive heart failure
Hypertension
Polypharmacy
Financial Limitations
