Rheum Pharm: Lupus and Gout Meds

Question 1

Meds to avoid (may cause SLE exacerbation)

4

Answer 1

Sulfa containing antibiotics

1. Sulfadiazine,
2. trimethoprim/sulfamethoxazole
3. Minocycline
4. Oral contraceptives

Question 2

Drug-induced lupus

3 most common?

Answer 2

1. Procainamide
2. Hydralazine
3. Griseofulvin

These meds do not seem to cause exacerbations of idiopathic lupus but may cause drug-induced lupus

Question 3

Medical therapy is targeted at the organ/system involvement

1. Antimalarials work for what? 2
2. Which drug?
3. May prevent what kind of damage? 2
4. May decrease what?

Answer 3

1. • cutaneous and
   • MSK involvement
2. Hydroxychloroquine (Plaquenil)
3. May prevent renal and CNS damage
4. May decrease disease flares

Question 4

Other meds for cutanous manifesations of SLE other than antimalarials?

Musculoskeletal?

Answer 4

1. Cutaneous
   Topical therapies whenever possible
2. Musculoskeletal
   NSAIDs

Question 5

SLE
Glucocorticoids for significant organ involvement
5

Answer 5

1. Cardiopulmonary
2. Hepatic
3. Renal
4. Hemolytic anemia
5. Immune thrombocytopenia

Question 6

SLE
Other immune modulators used for severe disease and when steroid resistant such as?
5

Answer 6

1. Methotrexate
2. Cyclophosphamide
3. Azathioprine
4. Mycophenolate
5. Rituximab

Question 7

If antiphospholipid antibody positive how should we treat?

Answer 7

Lifelong anticoagulation

Warfarin to achieve INR of 2-3

Question 8

Gout medications? 4

Answer 8

1. Indomethacin (Indocin)
2. Colchicine (Colcrys)
3. Allopurinol (Zyloprim)
4. Probenecid

Question 9

Pharmacologic management of gout
1. ACUTE ATTACK options?
(first through third line?)

2. Prevention of attacks? 3

Answer 9

1. NSAIDs #1
2. Colchicine #2
3. Steroids #3
4. Avoidance of meds that increase uric acid
5. Xanthine oxidase inhibitors
6. Uricosuric drugs

Question 10

Which NSAIDS would we used for acute gout attacks?

2

Answer 10

1. Naproxen

2. Indomethacin

Question 11

GOUT
Xanthine oxidase inhibitors
which drugs are these? 2

Uricosuric drugs: which drugs are these? 1

Answer 11

1. Allopurinol (Zyloprim)
2. Febuxostat
3. Probenecid

Question 12

GOUT

MOA of Xanthine oxidase inhibitors and Uricosuric drugs?

Answer 12

Decrease serum uric acid

Question 13

General principles of gout treatment
1. Start medications when?

2. Ok to stop treatment how long after symptom resolution unless on steroids then need a slower taper to prevent a rebound attack?
3. Do not initiate what therapies in acute gout?

Answer 13

1. as soon as patient perceives an attack coming on
2. 2-3 days
3. urate-lowering

Question 14

Acute Gout
1. When would we use colchicine?

2. When would we use corticosteriods? 2

Answer 14

1. Colchicine
   - Use if contraindications to NSAIDs
2. Corticosteroids
   - Use if contraindications to NSAIDs and Colchicine or
   - if other therapies fail to resolve symptoms

Question 15

GOUT:
1. NSAIDs MOA:
Inhibit what? 2

2. Contraindications? 6

Answer 15

In general inhibit

• cyclooxygenase and
• ultimately production of mediators of inflammation

2. • CrCl less than 60 ml/min,
   • active duodenal or gastric ulcers,
   • heart failure,
   • uncontrolled HTN,
   • allergy,
   • chronic anticoagulation

Question 16

GOUT: What specific mediators do NSAIDs indirectly inhibit? 3

Answer 16

1. Prostaglandins,
2. prostacyclin,
3. thromboxane

Question 17

GOUT
NSAIDs: Increased risk of what? 5

Naproxen at high doses does not seem to increase CV risks but at lower doses is similar to other NSAIDs
Risks seem to increase for long term use (> 1 month)

Answer 17

1. stroke,
2. MI,
3. CHF,
4. afib,
5. CV death

Question 18

GOUT
For patients on aspirin
When should we take NSAIDS?

Answer 18

Take ASA 2 hours prior to NSAID therapy

Question 19

NSAIDs for acute gout
1. Key to symptom relief is what?

2. ____ days of therapy is usual
3. Can reduce dose if needed after what?
4. Continue for about __ days after complete resolution of symptoms

Answer 19

1. beginning treatment at the onset of symptoms
2. 5-7
3. good symptom response
4. 2

Question 20

NSAIDs for acute gout
Which ones and at what dose?
3

Answer 20

1. Indomethacin (Indocin)
   50mg TID
2. Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
   500mg BID
3. Celecoxib (Celebrex)
   800mg initial dose then decrease to 400mg BID

Question 21

GOUT
NSAIDs for acute gout:
Dont prescribe Celecoxib (Celebrex) if what?

Answer 21

Avoid if history of sulfa allergy

Question 22

GOUT
Colchicine (Colcrys) for acute attacks
1. Use when?
2. Most likely to be effective if what?
3. Not beneficial for attacks ongoing for more than what?
4. If loading dose within the last 2 weeks, don’t do what?

Answer 22

1. Use if NSAID intolerance or contraindication
2. Most like to be effective if treatment started within 24 hours of symptom onset
3. Not beneficial for attacks ongoing for more then 72 hrs
4. If loading dose within the last 2 weeks, don’t repeat it

Question 23

GOUT
Colchicine (Colcrys)
1. Loading dose?
2. Followed by?
3. then (12 hrs later) move to dosing for prophylaxis of?

Answer 23

1. Loading dose of 1.2 mg
2. followed by a dose of 0.6 mg 1 hr later
3. then (12 hrs later) move to dosing for prophylaxis 0.6 mg QD or BID

Question 24

GOUT
Colchicine for acute attacks:
If already on chronic colchicine and attack develops give a what?

Answer 24

loading dose

Question 25

GOUT Colchicine 1. MOA? 2. Onset of action to pain relief? 3. Metabolism? 4. Half life? 5. Time to peak serum concentration? 6. Preg cat?

Answer 25

1. MOA: Prevents activation degranulation and migration of neutrophils associated with mediating some gout symptoms 2. Onset of action to pain relief: 18-24 hrs 3. Metabolism: Hepatic via CYP3A4 4. Half-life: 27-31 hours 5. Time to peak serum concentration: 30min to 3 hrs 6. Pregnancy cat: C

Question 26

GOUT Colchicine SE 6

Answer 26

1. Diarrhea up to 77% 2. Nausea 3. Vomiting 4. Reversible peripheral neuropathy 5. Bone marrow suppression 6. Myopathy

Question 27

GOUT Who is at risk for myopathy taking Colchicine? 7

Answer 27

1. At risk if renal dysfunction, 2. elderly or concomitant use of 3. Cyclosporine, 4. diltiazem, 5. verapamil, 6. fibrates, 7. statins

Question 28

GOUT Dose adjustment for colchicine needed in who?

Answer 28

1. > 70 years old 2. CrCl less than 30 ml minute 3. Avoid in dialysis patients

Question 29

GOUT | Colchicine Contraindications?2

Answer 29

1. Renal impairment | 2. Hepatic impairment

Question 30

GOUT If no relief of symptoms with colchicine then what should we do? 2

Answer 30

1. Add on a glucocorticoid | 2. OR may be used cautiously in conjunction with an NSAID (if not contraindicated)

Question 31

Administration types for glucocorticoids in GOUT? | 3

Answer 31

1. Intraarticular 2. Oral 3. IV and IM

Question 32

GOUT 1. Oral glucocorticoids when? 2 2. What med and what dose? 3. Why IV or IM?

Answer 32

1. - For those who cannot take NSAIDs, colchicine and - not candidates for joint injection 2. Prednisone 30-50mg daily until resolution then taper off over a week 3. IV or IM If not a candidate for any other route or medication

Question 33

Management between gout attacks | 2

Answer 33

1. Avoidance of meds that increase uric acid or inhibit renal excretion of uric acid 2. Uric acid reducing meds

Question 34

GOUT When are Meds to reduce serum uric acid are indicated? 3 Avoidance of meds that increase uric acid or inhibit renal excretion of uric acid. SUCH AS? 3

Answer 34

1. 2 or more episodes per year 2. Tophi 3. Chronic kidney disease, stage 2 or greater 1. Thiazide and loop diuretics 2. Niacin 3. Aspirin

Question 35

GOUT preventative therapy: 1. Wait how long after an acute attack to initiate prevention therapy? 2. Initiation of antihyperuricemic therapy can stimulate what? 3. Lowering the uric acid levels how can stimulate a gout attack? 4. Prophylactic _________ therapy is used when initiating urate lowering therapy to reduce attacks 5. Dosing?

Answer 35

1. 2 weeks 2. a gout attack 3. too quickly 4. colchicine 5. Colchicine 0.6mg Qday to BID

Question 36

What is the agent of choice for urate lowering?

Answer 36

Allopurinol (Zyloprim)

Question 37

Allopurinol (Zyloprim) 1. Class of drug? 2. Goal for seruem urate level is what? 3. Check when after dose adjustment? 4. Recheck in how long to confirm? 5. Recheck how often after that?

Answer 37

1. Xanthine oxidase inhibitor 2. Goal for serum urate level is less than 6 3. Check 2-4 weeks after dose adjustment 4. Recheck in 3 months to confirm 5. Recheck q 6 months to yearly

Question 38

Allopurinol (Zyloprim) 1. MOA? 2. Onset of action? 3. Half life? 4. Adjust dose for renal impairment how? 2 5. Normal adult dosing?

Answer 38

1. MOA: Inhibits xanthine oxidase needed for the eventual conversion of hypoxanthine to uric acid 2. Onset of action: 1-2 weeks 3. Half life: active metabolite 18-30 hrs 4. Adjust does for renal impairment - 100mg daily for CrCl >60 ml/min - Lower dose for CrCl

Question 39

Allopurinol (Zyloprim) SE? 8

Answer 39

1. Skin rash *D/C drug 2. Gout attack 3. Diarrhea 4. Nausea 5. Elevated liver enzymes 6. Hypersensitivity reactions* 7. Bone marrow suppression 8. Hepatotoxicity

Question 40

Allopurinol (Zyloprim) Hypersensitivity reactions* with what? 3 What should we be aware of with Bone marrow suppression?

Answer 40

1. ACEI 2. Amoxicillin/ampicillin 3. Diuretics Use with caution with other drugs that cause myelosuppression

Question 41

Preventative Gout med: | Second line agent if unable to take allopurinol?

Answer 41

Probenecid

Question 42

``` GOUT Probenecid 1. Class? 2. MOA? 3. Not effective if what? 4. Contraindicated when? ```

Answer 42

1. Uricosuric agent 2. Blocks tubular reabsorption of filtered urate and increases uric acid excretion by the kidney 3. Not effective if CrCl

Question 43

GOUT: Probenecid To prevent the development of uric acid stones 2

Answer 43

1. Patient education to increase fluid intake | 2. May need an agent to alkalinize the urine - potassium citrate to maintain urine pH > 6.0

Question 44

GOUT: These meds can also decrease uric acid levels. Such as? 4

Answer 44

1. Losartan 2. Fenofibrate 3. Vitamin C 500mg daily 4. Cherries

Question 45

Take home points on NSAIDs and steroids 1. Remember they cause what? 3 2. Need to monitor closely for _______ in patients at high risk for fluid retention and may need to adjust usual ________ doses during treatment

Answer 45

1. - fluid retention - HTN - significant CHF exacerbations 2. edema, diuretic Many, many hospital admissions for CHF have been caused by administration of these meds