- diarrhea - myopathy, rhabdo - bone marrow suppression

gout + antiinflammatories Flashcards by Sarah Hoffman

what do you screen for when someone has gout

HTN, DM, hyperlipidemia, CKD

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M/C cause of hyperuricemia

decreased excretion of urate by kidneys

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2 main categories of gout MANAGEMENT

xanthine oxidase inhibitors

uricosuric agents

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ACUTE gout anti-inflammatories

NSAIDS - naproxen > ibuprofen
prednisone (if CKD, cirrhosis, HF)
colchicine

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what two acute anti-inflammatory combos should you avoid & WHY

steroids, NSAIDS

can –> GI toxicity

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risk factor reduction for gout

weight loss, decrease CV risk factors, manage BP, exercise, hydration, smoking
decrease intake of SSB (fructose!!), organ meats, red meats, ETOH

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what pts should be on anti-hyperuricemic therapy

frequent/disabling gout attacks (>2/yr)
men <25 OR premenopausal women
gout w CKD

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ADRs of colchicine

diarrhea
myopathy, rhabdo
bone marrow suppression

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do not combine colchicine with…

3A4 or pgp inhibitors (clarithromycin, cyclosporine)

- statins, fibrates

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goals of serum [UA] in gout

<6 or <5 if tophi

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when do you initiate anti-hyperuricemic therapy

when acute gout attack has resolved

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xanthine oxidase inhibitors

allopurinol

febuxostat

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xanthine oxidase of choice

allopurinol

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what to screen for with allopurinol and why

HLA-B5801 –> at higher risk of DRESS

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what do you adjust for with allopurinol tx

GFR

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ADR of allopurinol

paradoxical gout flare
bone marrow suppression
drug fever
rash, DRESS

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BBW for febuxostat

cardiac safety concerns

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uricosuric agent

probenecid

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probenecid MOA

basically, urate diuretic

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before starting someone on probenecid, pts must have

good renal function - GFR >50

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pegloticase MOA

turns UA into a water soluble metabolite that can be excreted

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when would you use pegloticase

severe gout, debulking for tophi, last resort!

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biosimilars must have the same __ compared to OG drug

MOA
dose
strength
route

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how soon should you initiate non-biologic DMARD therapy

within 3 months of the diagnosis

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when should you use a biologic DMARD

when pt doesn't respond to non-biologic, have moderate disease, or intolerant to DMARD

triple therapy anti-inflammatory regimen

MTX + hydroxychloroquine + sulfasalazine

biologic therapy anti-inflammatory regimen

MTX + TNF-inhibitor

what to use to decrease inflammatory symptoms

low dose steroids, NSAIDS

immunizations for people with inflammatory conditions

``` influenza pneumonia (both) VZV HBV HPV ```

when should immunizations be given

1 month prior to initiating DMARD

non-biologic DMARDS

- MTX - leflunomide - sulfasalazine - hydroxychloroquine - JAK inhibitors (-citinibs)

MTX MOA

folate antimetabolite that inhibits DNA synthesis

indications for MTX

- tumors/CA - RA - psoriasis/psoriatic arthritis

monitoring for MTX

- CXR, PFT - HBV/HCV test - CBC, CMP

ADRs for MTX

- stomatitis - GI intolerance - pulmonary toxicity - hepatotoxicity (LFT abnormalities) - nephrotoxicity - bone marrow suppression

drug interactions of MTX

- other anti-folate drugs (TMP-SMX) - other drugs that affect kidneys (NSAID, transplant drugs, diuretics) - PPIs increase MTX conc.

what should you supplement MTX with & why

folate to decrease ADRs

when should you take pts off MTX & why

sick pts in hospital --> risk of aplastic crisis

reversal agent for MTX

levocovorin

leflunomide indications

RA/psoriatic arthritis in pt who had MTX toxicity

leflunomide ADRs

- diarrhea - reversible alopecia - LFT abnormalities

hydroxychloroquine indications

- RA - SLE - anti-malaria

do not use hydroxychloroquine if...

hx of retinal/visual field abnormalities | pts with renal insufficiency

hydroxychloroquine ADRs

- ophthalmic issues - QTC issues - hemolysis in G6PD pts

sulfasalazine indications

- RA | - IBD

common sulfasalazine ADRs

- GI intolerance | * sulfa rash!

JAK inhibitors

tofacitinib baricitinib upadacitinib

JAK inhibitor indications

mod-severe RA

what are pts on JAK inhibitors at risk of

thromboembolic events

1ST line TNF-inhibitors

- infliximab - adalimumab - etanercept

2nd line TNF inhibitors

certolizumab | golimumab

TNF inhibitors indications

- mod-severe RA - psoriatic arthritis - severe plaque psoriasis - IBD - ankylosing spondylitis - sJIA

what are TNF-inhibitors typically used with

MTX

screening for pts on TNF inhibitors

``` CA TB (IGRA, TST) CXR HIV HBV HCV ```

acute ADRs of TNF-inhibitors

injection site rxn infusion rxn URTI GI intolerance

serious ADRs of TNF inhibitors

- lupus - MS - bone marrow suppression - malignancies - increased risk for serious infections

what type of infections are pts on TNF inhibitors at risk of

TB reactivation invasive fungal infection bacterial infection

all other drugs biologic DMARDS (besides TNF-inhibitors) are generally only used for...

RA pts who dont respond to TNF inhibitor

T cell costimulation/activation inhibitor

abatacept

cd20 mab

rituximab

IL-1 antagonist

anakinra

IL-6 antagonist

toclizumab | sarilumab

acute psoriatic arthritis tx

NSAIDS, intraarticular or low-dose systemic steroids

long-term psoriatic arthritis tx

mild: NSAIDS | mod-severe: MTX, leflunomide --> add TNF-inhibitors if no improvement in 12-16 weeks --> then other agents

apremilast

PDE4 inhibitor | psoriatic arthritis

secukinumab

il-17 antagonist

ixekizumab

il-17 antagonist

ustekinumab

il-12/23 antagonist

what other non-biologic & biologic DMARD can you use for psoriatic arthritis

abatacept | tofacitinib

systemic juvenile idiopathic arthritis characteristics

daily high fever evanescent MP rash inflammatory polyarthritis

tx for mild-moderate sJIA

- NSAID - systemic glucocorticoid - or both

pts with sJIA with FEW systemic features (fevers)

- DMARD (MTX + TNFinhibitor)

pts with sJIA with prominent systemic features (fevers)

- high does corticosteroids - tocilizumab or anakinra - canakinumab

gout + antiinflammatories Flashcards

(73 cards)