Gout Therapeutics

Question 1

what are the main causes of gout

Answer 1

over production of uric acid or underexcretion of uric acid

Question 2

what can cause overproduction of uric acid

Answer 2

Enzyme variability
Cytotoxic medications
Increase dietary intake of purines
chronic alcohol intake

Question 3

what can cause under excretion of uric acid

Answer 3

dehydration
insulin resistance
acute alcohol intake
medications

Question 4

what are the 3 main meds that lead to gout

Answer 4

Diuretics
Cytotoxic drugs
Salicylates

Question 5

Presentation of acute gout

Answer 5

-podagra
-UA deposits elsewhere
-fever
-intense pain
-swelling at joints

Question 6

what UA level is elevated

Answer 6

above 6.8

Question 7

what are complications of acute gout

Answer 7

-Tophi
-Nephrolithiasis
-Nephropathy

Question 8

What is the general treatment approach for treating gout

Answer 8

-treat pain
-use ULT to prevent recurrence
-anti-inflammatory prophylaxis

Question 9

Non pharm gout treatment

Answer 9

modify risk factors
applying ice
no supplements

Question 10

What are the NSAIDs for gout

Answer 10

Indomethacin
Naproxen
Ibuprofen
Sulindac

Question 11

Tapering for prednisone

Answer 11

7-10 days

Question 12

What is the MOA of colchicine

Answer 12

disrupts cytoskeletal functions by inhibiting tubules

Question 13

when to administer colchicine for acute attack

Answer 13

within 24 hours

Question 14

what is the colchicine dosing

Answer 14

Day 1: 1.2mg PO once then 1 hour later
Day 2+: 0.6mg BID until attack resolves

Question 15

Colchicine AEs

Answer 15

Neutropenia
Axonal neuromyopathy

Question 16

Do you renally adjust colchicine

Answer 16

yes

Question 17

Colchicine dose with CrCl less than 30

Answer 17

1.2mg onset, 0.6mg 1 hour later (once)
tx should be repeated no more than once every 2 weeks

Question 18

Colchicine dose with dialysis

Answer 18

single 0.6mg dose
tx should not be repeated more than once every 2 weeks

Question 19

When should you switch from colchicine

Answer 19

less than 50% improvement in pain in 24hrs

Question 20

What to do with inadequate colchicine response

Answer 20

switch agents
add 2nd agent

Question 21

What is the pill-in-pocket method

Answer 21

using abortive agent when gout onset comes on

Question 22

Diet changes for gout

Answer 22

DASH diet
avoid foods with saturated fats and sweetened bevs/food
alcohol restriction
limit high fructose corn syrup and organ meats

Question 23

when to start ULT

Answer 23

more than 2 gout flares/year
tophus
first flare w/ either CKD, uric acid above 9, urolithiasis

Question 24

who is not a candidate for ULT

Answer 24

asymptomatic hyperuricemia
first gout attack w/o risk factors

Question 25

what are risk factors for gout

Answer 25

male post-menopausal elderly obesity diet & alc intake sedentary renal impairments

Question 26

when to initiate ULT

Answer 26

wait 2 weeks after acute attack

Question 27

how long should ULT last

Answer 27

life long

Question 28

what UA level should you target for ULT

Answer 28

less than 6

Question 29

what is first line for ULT

Answer 29

Allopurinol and Febuxostat

Question 30

what is the initial dose of allopurinol

Answer 30

100mg PO daily

Question 31

how to titrate allopurinol

Answer 31

every 2-4 weeks in 100 mg increments

Question 32

what is the max dose of allopurinol

Answer 32

800mg/day

Question 33

what is the initial dose of Febuxostat

Answer 33

40mg daily

Question 34

how to titrate febuxostat

Answer 34

titrate to 80mg daily

Question 35

max dose of febuxostat

Answer 35

max dose 120mg/day

Question 36

should you renally adjust allopurinol

Answer 36

yes

Question 37

allopurinol dose eGFR less than 60

Answer 37

initial dose 5mg titrate slowly

Question 38

what are the DDIs with allopurinol

Answer 38

loop and thiazide diuretics warfarin

Question 39

what is the severe reaction to allopurinol

Answer 39

SJS and TEN

Question 40

what gene should be tested for allopurinol

Answer 40

HLA-B*5801

Question 41

main counseling for allopurinol

Answer 41

take this med even when you do not have gout symptoms

Question 42

what is second line ULT

Answer 42

Probenecid

Question 43

Probenecid initial dose

Answer 43

250mg PO BID x1-2 weeks up to 500mg BID

Question 44

Probenecid titration

Answer 44

Titrate by 500mg increments every 1-2 weeks

Question 45

Probenecid max dose

Answer 45

2g/day

Question 46

Probenecid ADR

Answer 46

Urolithiasis

Question 47

what should you consider before probenecid

Answer 47

G6PD deficiency not recommended in eGFR less than 60

Question 48

what DDIs are there for probenecid

Answer 48

antibiotics

Question 49

what is 3rd line for ULT

Answer 49

Pegloticase

Question 50

when to use Pegloticase

Answer 50

used in severe gout and hyperuricemia patients not responsive to subcutaneous tophi

Question 51

what formulation is pegloticase

Answer 51

IV infusion

Question 52

what is the dose of pegloticase

Answer 52

8mg IV every 2 weeks

Question 53

Pegloticase pearls

Answer 53

patients may develop antibodies

Question 54

When to start gout prophylaxis

Answer 54

initiating ULT

Question 55

what is the duration of gout attack prophylaxis

Answer 55

first 3-6 months of ULT initiation

Question 56

what agents can be used for gout prophylaxis

Answer 56

NSAIDs Prednisone Colchicine

Question 57

Colchicine prophylactic dose

Answer 57

0.6mg once or twice daily

Question 58

prophylactic colchicine dose with CrCl less than 30

Answer 58

0.3mg daily

Question 59

prophylactic colchicine dose on dialysis

Answer 59

0.3mg twice weekly