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PR3154 > IC17 Management of Gout > Flashcards

IC17 Management of Gout Flashcards

1
Q

What is gout?

A

Gout is a type of inflammatory arthritis that causes pain and swelling in your joints.

Gout flares often begin in your big toe or a lower limb.

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2
Q

What causes gout?

A

Gout is caused by:
1. Imbalances in purine metabolism
2. Purine is broken down into uric acid
3. Uric acid then precipitates out as uric acid crystals
4. Deposition of urate crystals in the articular & periarticular tissues (aka tophi)

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3
Q

What are the 5 risk factors of gout?

A
  1. Diet
  2. Obesity
  3. Male
  4. Genetics
  5. Kidney disease
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4
Q

What are the 2 main targets for pharmacotherapy management in gout?

A
  1. Xanthine oxidase
  2. Increasing uric acid excretion
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5
Q

What can cause hyperuricaemia?

A
  1. Overproduction of uric acid
  2. Under-excretion of uric acid

If pt has hyperuricaemia, but show no S&S, there is no need to treat.

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6
Q

What are the clinical presentations of gout?

A
  1. Redness
  2. Warmth
  3. Swelling & tenderness
  4. Often presents at the big toe
  5. Attack often occurs in the early morning after waking up
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7
Q

What is the criteria to diagnose a pt w gout?

A

We diagnose a pt w gout via testing of:

  1. Synovial fluid
  2. Tissue sections of tophaceous deposits

If urate crystals are present in the synovial fluid, we diagnose a pt with gout.

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8
Q

What would synovial fluid look like with and without urate crystals?

A

Without urate crystals, synovial fluid is:
- Colourless & translucent
- <200 WBCs/mm^3
- No crystals present

With urate crystals, synovial fluid is:
- Yellow & cloudy
- 2000-50,000 WBCs/mm^3
- Crystals present

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9
Q

What are the 5 treatment goals for gout?

A
  1. Provide rapid, SAFE, & effective pain relief
  2. Reduce future attacks
  3. Prevent joint destruction & tophi formation
  4. Increase QoL
  5. Address associated comorbidities
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10
Q

What is considered hyperuricaemia in men & women?

A

Men: Plasma uric acid >7mg/dL
Women: Plasma uric acid >6mg/dL

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11
Q

How to manage acute gout flares?

A

Treat pt w:
- Colchicine (within 24hrs) - 1st line
- Oral NSAIDs
- Oral glucocorticoids

If pt is already on Urate Lowering Therapy (ULT), continue ULT during flare.

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12
Q

What are the 2 ways to give colchicine for acute gout flares?

[DIFFERENT FROM PROPHYLAXIS TREATMENT]

A
  1. One-off treatment
    - 1mg loading dose + 0.5mg 1hr later
  2. Continuous treatment
    - 0.5mg 2-3 times a day, until acute flares resolves
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13
Q

How is colchicine given for prophylaxis treatment?

A

Colchicine 0.5mg OD* for 3-6 months

Note that Colchicine is given OD and not 2-3 times daily as compared to acute treatment.

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14
Q

What are the ADRs of colchicine?

A
  1. N&V
  2. Diarrhoea

ADRs increase w higher dose or long term use.

Colchicine can be discontinued after gout attacks are gone.

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15
Q

What should we avoid if there is an acute gout flare?

A

We should avoid using ULT - (allopurinol, febuxostat & probenecid) in acute flare attacks.

Reason: They can cause mobilisation or uric acid. We should wait 2-4 weeks after the acute gout flare before giving ULT.

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16
Q

Colchicine toxicity is more likely to occur in renally impaired pts.

What should we do for renally-impaired pt with acute gout flares?

A

Lower the dose of colchicine to give.

Avoid giving oral NSAIDs to renally impaired pts.
Oral NSAIDs are CI in pt w CrCL<30ml/min.

17
Q

What are the criteria to initiate ULT?

A

Pt is only eligible for ULT if:
1.Pt has ≥2 acute gout flares a year
2. Presence of tophi or tophus
3. Imaging showing joint damage
4. History of kidney stones (urolithiasis)

18
Q

What are the treatment targets when using ULT?

A

Treatment target:
Non-tophaceous gout: <360µmol/L (6mg/dL)

Tophaceous gout: 300µmol/L (5mg/dL)

19
Q

What is the MOA of allopurinol & febuxostat?

A

They inhibit xanthine oxidase.

20
Q

What is the MOA of probenecid?

A

It increases the excretion of uric acid.

21
Q

What is the ADR of allopurinol?

A

There is a risk of SCAR - subcutaneous adverse reactions, e.g SJS, TEN, DRESS.

We can conduct genetic testing for HLA-B*58:01 in pt at higher risk for SCAR.

We should lower the dose of allopurinol in renally impaired pts

22
Q

What is the acronym for pt at higher risk of SCAR when taking allopurinol?

A

RASHES

R - renal impairment

A - Agent concomitant use of therapeutic agent, such as diuretics

S - Starting dose of allopurinol is high

H - HLA-B*5801 is present

E - Escalation of allopurinol dose is rapid

S - Seniority / older age

23
Q

What are the 4 S&S of SCAR?

A
  1. Flu-like symptoms - fever, body aches
  2. Mouth ulcers or sore throat
  3. Red or sore eyes
  4. Rash
24
Q

What should we be cautious of when using febuxostat?

A
  1. Cautious in pt w hepatic impairment.
  2. Use w caution in HF & CHD pts.
  3. Has risk of SCAR, but lower than allopurinol
25
Q

What should we be cautious of when using probenecid?

A
  1. Not recommended in pt with renal impairment (CrCl<50ml/min)
  2. CI in urolithiasis (kidney stones)
  3. Not effective in CKD pt.
26
Q

What is the dosing for allopurinol?
- Initiation dose
- Maintenance dose

A

Initiation dose: ≤100mg/day

Maintenance dose: >300mg/day

“Start low, go slow”

27
Q

What is the dosing for febuxostat?
- Initiation dose
- Maintenance dose

A

Initiation dose: ≤40mg/day

Maintenance dose: 80mg/day

Febuxostat is given if pt is intolerant to allopurinol

28
Q

When do we stop ULT?

A

We can choose to stop ULT if clinical remission is achieved.

Clinical remission = no flares for ≥1 year and no tophi.

If therapy is well-tolerated & not burdensome, pt can have preference to continue or stop treatment. Shared decision is needed.

29
Q

What are non-pharmacological treatment for gout?

A
  1. Limit alcohol intake
  2. Limit purine-rich foods
  3. Limit high-fructose corn syrup
  4. Weight management
30
Q

What are examples of high-purine food?

A
  1. Asparagus
  2. Cauliflower
  3. Mushroom
  4. Red meat
  5. Anchovies
  6. Durian
  7. Durian
  8. Peanuts
  9. Organ meat (e.g liver)

PR3154 (19 decks)

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