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CDM 2 Exam 2 > Lecture 6 - Gout 1 > Flashcards

Lecture 6 - Gout 1 Flashcards

1
Q

Hyperuricemia

A

Elevated Serum Uric Acid

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2
Q

Tophus

A

Calculus contains sodium rate that develops around fibrous tissues around joins, typically in patients with gout

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3
Q

Podagra

A

Painful condition of big toe caused by gout

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4
Q

Uricase

A

enzyme that oxidatively degrade uric acid, thereby catalyzing conversion to soluble allantoin, which is more soluble than uric acid

found in most animals, not in humans

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5
Q

Uricosuric meds

A

Meds given to increase elim of uric acid

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6
Q

Uric Acid Pathway

A

Hypoxanthine (Via Xanthine Oxidase ) -> Xanthine (via Xanthine Oxidase) - > Uric Acid (excreted by kindey, metabolized via rate oxidase in animals)

Gets converted to Allantoin in animals

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7
Q

Uric acid comes from?

A

Metabolism of purines

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8
Q

How is Uric acid eliminated in humans?

A

Gut and Kidney

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9
Q

Hyperuricemia SUA

A

> 7mg at 37C for men

> 6mg at 37C for women

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10
Q

Do all patients with hyperuricemia develop acute gout flares?

A

No

in absence of gout, asymptomatic hyperuricemia does not require treatment

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11
Q

Best description of gout?

A

Patients with gout will have recurrent acute attacks separated by intercritical periods

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12
Q

Risk Factors for Gout

A
  1. Inc age
  2. Male > female
  3. injury
  4. Hyperuricemia** most important
  5. Fasting
  6. Recent srugery
  7. Food/drinks
  8. Meds
  9. Medical conditions
  10. Genetics
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13
Q

Food/Drink risk factors for Gout

A

Food high in purine = red meat
Foods/drinks w/ high fructose corn syrup = soda
Alcohol

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14
Q

Meds that can cause overproduction

A

Cytotoxic chemotherapy

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15
Q

Meds that can cause under excretion

A

Cyclosporine + Tacrolimus
Diuretics (loop/thiazide)
Niacin
Low dose salicylates (< 2g/day)

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16
Q

Medical Condition Risk factors pointed out

A

Overproduction:
Myeloproliferative disorders
Lymphoproliferative disorders

Underexcretion:
Renal insufficiency
Volume depletion
CVD, common Risk factors

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17
Q

Risk Factors: Genetics

A

HGPRT deficiency: Leads to more Guanylic acid, leading to more uric acid

PRPP over activity: can increase Hypoxanthien leading to uric acid

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18
Q

Acute Goute Pathophysiology

A

Uric acid crystals deposit into joint, bringing immune cells that cause them to rupture and perpetuates an inflammatory response

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19
Q

Acute Gout Presentation

A

12-24hrs after exposure to risk factor

lower extremities

redness, swelling, warmth, extreme pain of the joints

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20
Q

Mot common areas for gout attack

A

big toe joint = paragraph

can get in knee, finger, wrists elbows

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21
Q

Difference with pseudo gout?

A

caused by calcium pyrophosphate crystals

can only tell by “tapping joint” looking at fluid after microscope

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22
Q

How to get diagnosis of gout?

A

Tapping joint and looking at fluid under microscope = gold standard

if cant do that, often do clinical diagnosis

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23
Q

Acute Gout management Treatment

A

want to rapidly relive symptoms

prevent recurrent attacks

prevent complications associated with chronic deposition of urate crystals

self limiting, can go away on its own but don’t want to do that

** Dont dx ULT in acute attack **

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24
Q

Nonpharm treatment options of Gout

A

Ice
Rest affected point
Patient education

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25
Pharm treatment options of Gout
Colchicine NSAIDs Steroids (systemic/intra-articular) IL-1 antagonists
26
FDA approved NSAIDs for gout
Indomethacin (Indocin) Naproxen (Naprosyn) Sulidac (Clinoril)
27
NSAIDs ADR
Inc BP, NA/Water retention, gastritis, GI bleeding
28
NSAIDs CI
Hx of allergy HF Renal Insufficiency Hx of previous GI
29
NSAIDs DI
``` ACE/ARBs Cyclosporine Tacrolimus Tenofovir Lithium Anti-platelet/anticoag Corticosteroids ```
30
NSAIDs monitoring efficacy
efficacy, lower pain, reduced number of flairs
31
NSAIDs monitoring safety
``` CBC LFTs SCr Fecal occult blood test Black tarry stools BP Edema ```
32
Corticosteroids MOA
Synthetic glucocorticoid analog used for anti-inflammatory effects
33
Corticosteroids ADR
Acute: Hypoglycemia, leukocytosis, fluid retention, impaired wound healing, GI, insomnia, Hypertension Chronic: HPA axis suppression, osteoporosis
34
Corticosteroids Precautions
Infection DM Peptic ulcer disease
35
Corticosteroid DI
Strong CYP3A4 inhib Fluoroquinolone NSAIDs anti-hyperglycemic agents
36
Corticosteroid Pt education
monitor BG if DM Take w/ food or milk to minimize GI upset
37
Colchicine MOA
May interferon w/ intracellular assembly of the inflammasome complex present in neutrophils and monocytes that mediates the activation of IL-1B
38
Prophylaxis Colchicine Dose
0.6mg or BID for ~6 months Req renal adjustment in bad renal impairment adjustment in severe hepatic impairment
39
Treatment of gout Flair Colchicine Dose
7 days at 1.2mg once, then 0.6mg one hour later Req renal adjustment in really bad renal impairment adjustment in severe hepatic impairment
40
If combo Hepatic/renal impairment can you use Colchicine?
nah
41
Colchicine Side effects
GI = diarrhea Blood dyscrasuas Neuromuscular toxicity
42
Colchicine CI
Patients w/ renal or hepatic impairment should not use w/ PGP or Strong CYP3A4 inhibitor
43
Colchicine DI
Strong CYP3A4, PGP inhib Statins & Fenofibrates Req dose adjustments if current on meds, or if recently on meds (within last 14 days)
44
Colchicine Monitoring
Efficacy: signs/symptoms of gout, dec gout flares Safety: CBC, signs/symptoms, GI
45
Colchicine Pt education
Appropriate dosing ADE Avoid Grapefruit juice
46
Anakinra Brand
Kineret
47
Canakinumab brand
Illaris
48
rilonacept Brand
Arcalyst
49
Which IL-1 agent only used for prophylaxis?
Rilonacept (Arcalyst)
50
IL-1 Antagonist SE
injection site reactions Neutropenia Hypersensitivity reactions infectious disease
51
IL-1 Antagonist CI
Hypersensitivity
52
IL-1 Antagonist DI
Immunosuppressants | Live vaccines
53
IL-1 Antagonists monitoring
Neutrophil count Temp Signs of infections
54
IL-1 antagonist Pt education
``` Report signs of infection Screen for TB avoid live vaccines SE proper injection ```
55
IL-1 Antagonists
Anakinra (Kineret) Canakinumab (Illaris) Rilonacept (Arcalyst)
56
Corticosteroids
Prednisone (Deltasone, Prednicort) Methylprednisolone (Medrol) Triamcinolone IM (Kenalog) Triamcinolone acetonide intraarticular
57
How to select Gout agent for patient?
``` Patient Preferences Current attack Response to current therapy Comorbid conditions DI Cost of therapy ```
58
Acute Gout Med to avoid in CKD
NSAIDs Cox-2 inhibitor Colchicine
59
Acute Gout med to avoid in Liver disease
NSAIDs Cox-2 inhibitor Colchicine
60
Acute Gout med to avoid CHF
NSAIDs Cox-2 inhibitor Corticosteroids
61
Acute Gout med to avoid HTN
NSAIDs Cox-2 inhibitor Corticosteroids
62
Acute Gout med to avoid ASCVD
NSAIDs | Cox-2 inhibitor
63
Acute Gout med to avoid PUD
NSAIDs Cox-2 inhibitor Corticosteroids
64
Acute Gout med to avoid Diabetes
Corticosteroids
65
Acute Gout med to avoid Infection/Infection Risk
Corticosteroids | IL-1 antagonists
66
Acute Gout med to avoid Geriatric Patients
Indomethacin
67
1st line therapy for Acute Gout
NSAIDs Colchicine Glucocorticoids All preferred over IL-1 antagonists Low dose Colchicine > High Dose IL-1 used if pts cant tolerate or take others
68
1st line therapy for Acute Gout
NSAIDs Colchicine Glucocorticoids All preferred over IL-1 antagonists Low dose Colchicine > High Dose IL-1 used if pts cant tolerate or take others
69
Treatment Goals for chronic Gout?
Maintain SUA of < 6mg/dL
70
Strongly Recommend to Start ULT
> 1 tophi Radiographic damage attributable to gout frequent Gout flares > 2/yrs
71
Conditionally Recommended to Start ULT
Pts w/ >1 flare but have <2/yr pts experiencing 1st flare and have > Stage 3 CKD, SUA > 9 or urolithiasis
72
Patients recommended against Start ULT
pts experiencing 1st flare with exceptions Asymptomatic hyperuricemia
73
What to do before starting ULT?
1st initiate prophylactic therapy for mobilization flares Low dose colchicine NSAIDs (give with PPI due to length on them ~ 6 month) Corticosteroids
74
How long should Prophylactic therapy last for mobilization therapy before ULT?
3-6 months possible to extend if still experiencing flares
75
Allopurinol MOA
Xanthine Oxidase inhibitors
76
Allopurinol Dosing
Start 50 or 100mg daily (depend on renal function), titrate up by 50-100mg every 2-5 weeks until goal of SUA < 6mg/dL Doses > 300mg often given in divided doses Max daily Dose = 800mg
77
When to use 50mg Allopurinol Dose
Stage 4 CKD or higher
78
when to use 100mg Allopurinol Dose
Everyone, incl blew Stage 4 CKD

CDM 2 Exam 2 (16 decks)

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