i'd pout if i had gout Flashcards
(47 cards)
1
Q
Gout
A
- a form of inflammatory arthritis
- deposition of uric acid crystals in joints
- Purines (adenie and guanine from diet and tissue breakdown) → metabolized into uric acid → uric acid >6.7 → precipitates into crystals in joints → immune response triggered
- Excess serum uric acid can calso be caused by overproduction of urate or underexcretion of urate
2
Q
diseases that promote hyperuricemia
A
- Insulinse resistence (DM)
- HLD
- Obesity
- REnal insufficiency CKD
- HTN
- Organ translplant
- CHF
3
Q
hyperuricemic foods
A
- Meat
- Seafood
- Beer and liquor
- Soft drinks
- Fructose
ead to increased uric acid levels in the body
4
Q
Uricosuric foods
A
- Coffee
- Low-fat dairy
- VitC - don’t recommend though
help clear uric acid from body
5
Q
Hyperuricemic meds
A
- TZDs
- Loop diuretics
- nicotoninc acid
- Asa <1g / day
6
Q
Uricosuric meds
A
- Losartan
- Fenofibrate: but like don’t go around recommending fenofibrate
7
Q
Gout flare
A
- rapdi onset (<24hrs) of severe pain, erythema and swelling in a single or multiple koints
- can be precipitated by
- EtOH ingestion
- high purine ingestion
- stress
- meds - including UA lowering ageents
8
Q
Podagra
A
big toe joint ← most common joint to be involved in gout
9
Q
Interval gout
A
asymptomatic between attacks
10
Q
Tophaceous gout
A
- deposits of mass of crystals in soft tissues, joints, cartilate, or bone
- Can cause soft tissue damage, deformity, joint destruction, and nerve compression syndromes (carpal tonnels)
11
Q
atypical gout
A
polyarthritis affecting any joing, may be confused with RA or OA
12
Q
gouty neprhopathy
A
kidney stones
13
Q
goa of therapy for acute gout
A
reduce pain and reduce duration of attack ← treat with anti-inflammatory med
14
Q
NSAID dosing in gout
A
- Start medication <24hrs from onset of attack
- Resolution of symptoms within 5-8 days, tho may be longer and can take NSAIDs for longer PRN
15
Q
What population to avoid NSAIDs in
Not necessarily hard CI
A
- Rena insuffiiency/failure
- Bleeding disorders or anticoagulated pts
- PUD
- CHF
- > 75 y/o
16
Q
colchicine standard actue dosing
A
1.2 mg (2T) PO to start and then 0.6 (1T) again 1hr later the can start ppx dosing in 12 hrs
canNOT use for acute if used for flare in last 14 days
Do not use for flare at all if CYP3a4i or pgpi
17
Q
colchicine standard chronic dosing
A
0.6mg PO QD or BID
18
Q
When to dose adjust colchicine
A
- renal/hepatic impairment
- CrCl < 30
- CYP3A4 and PGP inhibitor DDI
- CI though if DDI + renal/hepatic impairment
19
Q
Strong CYP3A4 inhibitors and what dose ajustments are made with colchicine doses (acute and chornic)
A
- clarithromycin
- darunavir/ritonavir
- itraconazole
- ketoconazole
- acute: 0.6mg PO then 1 hr later 0.3mg (do not take again for 72 hrs)
- chronic: 0.3mg QOD or QD
20
Q
Moderate CYP3A4 inhibitors and what dose ajustments are made with colchicine doses (acute and chornic)
A
- dilt
- erythromycin
- fluconazole
- verapamil
- acute: 1.2mg PO (do not take again for 72 hrs)
- chronic: 0.3-0.6mg QOD or QD (can also do 0.3mg BID)
21
Q
PGP inhibitors and what dose ajustments are made with colchicine doses (acute and chornic)
A
- cyclosporine
- amiodarone
- ranolazine
- acute: 0.6mg PO (do not take again for 72 hrs)
- chronic: 0.3 QOD or QD
22
Q
Colchicine AE
A
- GI “titrate to diarrhea”
- Hematologic abnormaltiies
- Rhabdo
- Increased risk if renal dysfunction and elderly
- Increased risk of myopathy if conmittant CYP3A4 inhibitors, PGP inhibitors, fibrates, and statins
23
Q
Are corticosteroids safe in renal impairment?
A
Yes
24
Q
PO corticosteroid dosing in acute gout flare
A
- Prednisolone or prednisoe 0.5mg/kg
- full dose PO QD 5D then stop (preferred)
- full dose PO QD 2D then taper off over 10D
- Medrol dose pack
25
intra-articular corticosteroid dosing in acute gout flare
- trimacinolone - if gout attack is >3 jonts, systemic therapy necessary
- large joint (knee): 40mg
- medium joint (wrist, ankle, elbow): 30mg
- small joint (toe, finger): 10mg
26
Corticosterod AE
- leukocytosis
- increased appetite
- mood changes
- elevated blood glucose
27
What population to avoid corticosteroids in
- DM
- CHF
- severe GERD or PUD
28
Chronic gout goal of therapy
prevent future attakcs and hyperuricemic sequlae by **maintaining uric acid level <6.0**
29
Allopurinol osing
- Starting dose:100mg QD
- CKD stage 4 or worse *starting* dose: 50mg PO QD
- Can go above 300mg QD if needed
- Increase Q2-5W to reach target SUA <6mg
- can go all the way up to 800mg QD
30
allopurinol DDIs
- Xanthine oxidase involvement *-*
- Warfarin *decrease dose of warfarin*
- 6-MP - CI
- Azathioprine - CI
- Theophylline - CI
- Can cause rash
- Amoxicillin
- Ampicillin
- TZDs
- ACE
31
allopurinol AE
- Rash: if developed, d/c med, can develop into JS
- INcreased risk if conmittant use with amoxiciilin, amipicillin, TZDs, ACE
- DRESS: if developed, dc drug
- Rash + fever + eosinophilia + hepatitis
32
febuxostat dosing
- Dosing: 40g PO QD
- Can increase to 80mg PO QD in pts who have NOT achieved SUA of <6 after 2 weeks
- NO dose adjustment for mild-moderate renal or hepatic impairment
33
febuxostat AE
- HA
- arthralgias
- abdominal pain
- nausea
- abnormal LFTs
- flushing dizziness
- BBW:CV event related death ← **don’t start in pts wth CV disease**
34
Febusostat DDI
**conraindications**
- 6-MP
- azathiorpine
- theophylline
35
probenecid dosing
- 250mg PO BID
- May icnrease dose after 7 days to 500mg PO BID to achieve SUA <6
- Increase dose further Q4W by 500mg increments to a max TDD 2g
36
What population to avoid probenecid in
- CrCl <50
- Hx of kidney stones
- conmittant use of:
- Increased [ ] of prbenicid d/t renal secretion
- penicillin
- methotrexate
- carbapenems
- Decreased efficacy of probeneicid
- salicylates
37
Pegylated recombinat uricase (pegloticase) dosing
8mg IV infused over 2h Q2W
## Footnote
ppx iwth low dose colchicine or NSAID for 6mo. before starting
38
Pegylated recombinat uricase (pegloticase) AE
- infusion related reactions
- Pre-medicate iwth antihistamines and corticosteroids
39
What agents are uric acid lowerign therapies (ULT)?
- allopurinol (first line)
- feuxostat
- probenecid
- pegloticase: indicated if other itervventions have failed to achieve goal UA level and pt continues to have 2+ flares/year or non-resolving tophy
40
lifestyle modifications for gout pts
- imit EtOH, purine, high-fructose corn syrup intake
- Wt loss if overweight
41
Who qualifies for chronic gout therapy?
- Indications for pharmacologic treatment: 1 of the following
- 1+ SQ tophi
- Radiographic evidence of damage attributable to out
- 2+ flares a year
- *Consider* if one of the follwoing
- Hx of 1 attack but <2 a year
- Thsoe with first gout flare with the following
- CKD stage 3
- UA >9
- kindey stones
42
does chronic gout therapy stop when pt ahs a flare?
NO
43
What agents are gout flare **ppx**?
- First line:
- Low dose colchicine
- Low dose NSAID
- Second ilne: for if both first line agents are not tolerated, CI or ineffective
- low dose prednisone or prednisolone (<10mg per day)
44
when is gout flare ppx therpay started?
3-6 months of flare ppx is initiated alongside initiation of ULT
45
When can we stop gout flare ppx
- If s/s of gout, flare in past 3 mo.s or palpable tophi, continue use
- if pt had *no* tophi, can stop flare ppx 3 months after UA level is met and resolution of s/s
- if pt *had* tophi, can stop flare ppx 6 months after UA level is met and resolution of s/s
46
When an we use monotherpay in acute gout *flare* and what are the monotherpay optiosn
if mild-oderate pain, pariticualry for an attack affecting only a few small joints or 1-2 large joints
## Footnote
- NSAID
- systemic corticosteroid
- colchicine: if pt is already on colchicine theray and has NOT received acute colchicine therapy in past 14 days, can use colchicine, otherwise try NSAID
- IF INADEQUATE RESPONSE: try another mootherapy or add on another
47
When an we use combo therapy in acute gout *flare* and what are the options
if severe pain, paritulary for a polyarticular atack or an attack affecting ultiple large joints
## Footnote
any combination of (EXCEPTION: NO NSAID AND PO STEROID)
- NSAID
- colchiine
- PO corticosteroid
- intra-articular steroid (only in triple therpay)
