Therapeutics - Gout part 2 Flashcards by amanda kastel

symptoms of colchicine toxicity begin within…

2-5 hours

may lead to organ failure within 24-72hrs

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doses of colchicine as small as___ have been fatal

8mg

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name some treatment for colchicine toxicity

stomach pumping (gastric lavage)
activated charcoal

is NOT dialyzable

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dose of colchicine as PROPHYLAXIS

0.6mg QD or BID for 3-6 months after starting UA lowering therapy to prevent attacks from starting the XO inhib

if they feel attack - start using flare doses (1.2mg stat and 0.6mg 1 hour later)

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in what patients is colchicine used as prophylaxis

pts who have recurrent attacks and NORMAL URIC ACID (allopurinol wont help)

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corticosteroids are ____ line for gout

3rd line

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what steroid is typically given IA and which 2 typically IM

IA - trimcinolone

IM - triamcinolone or methylprednisolone

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approx how long is oral corticosteroid therapy?

what is dose

important considerations

around 10-14 days

0.5mg/kg/day of prednisone for 5-10 days OR 2-5 days and then taper off for 7-10 days

DONT WANT REBOUND FLARES - taper off

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corticosteroids should be used in caution in pts with which 3 health conditions

HTN
CHF
diabetes

can cause hyperglycemia and sodium and water retnetion

however, only given short term so not really the biggest concert

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if all 3 agents (NSAIDS, colchicine, CS) are ineffective/cant be used, what can be used?

(NAME 2)

IL-1 inhibitors

anakinra and canakinumab

considered off label

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give 2 scenarios in which urate lowering therapy (prevention) should NOT BE USED

-if UA is only mildly elevated (like around 8)

-if the first episode was mild and responsed well to treatment

watch and see first if UA levels go down or if they have more attacks 1st

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4 scenarios in which UA lowering therapy SHOULD be started

-have frequent attcks (2 or more in a year) - discuss with pt

-have uric acid kidney stones - CKD stage greater than or equal to 2

-evidence of tophi for greater than or equal to a year (sign of more longstanding disease)

-have chronic joint damage from the gout – dont want further disability

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definition of hyperuricemia

serum UA is GREATER THAN 7mg/dL

as mentioned - if it’s 8 - dont start urate lowering therapy yet

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if a pt has hyperuricemia but no symptoms of flares or tophi, should it be treated with urate lowering therapy?

NOO

MIGHT consider if it’s very severely elevated

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scenarios in which we may consider urate lowering therapy in someone that just had 1 gout attack

the UA level greater than 9

have mod-severe CKD

-kidney stones (urolithiasis)

pts on chemo or radiotherapy (tumor lysis syndrome)

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if a pt is on chemo and at risk of tumor lysis syndrome, what may they be treated with

allopurinol or rasburicase (specific for hyperuricemia with chemo)

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name the 4 classes of drugs approved for urate lowering therapy

XO inhibitors

uricosurices

uricase agents

URAT 1 (uric acid transporter 1) inhibitor

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name 2 XOIS

allopurinol and febuxostat

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name a uricosuric agent

probenecid

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name a uricase agent

pegloticase

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name URAT 1 inhibitor

lesinurad

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ULT (urate lowering therapy) drugs are given with _____ for _______ to prevent _______

anti-inflammatories for 3-6 months to prevent gout caused by initiating ULT

ex: colchicine, NSAIDS, prednisone

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target UA when using ULT

less than 6mg/dL

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true or false

ULT treatment is stopped after 3-6 months of improvement

FALSE

it’s continued forever

1st line ULT

allopurinol

true or false XOIs are useful for BOTH under excreters and over prodicuers

TRUE

can allopurinol be used in CKD?

yes - just need to lower the dosing

regular dosing of allopurinol

100mg/day increase every 4 weeks to 200-300mg a day some pts may need 600-800 a day

monitoring parameters for allopurinol

serum UA (obviously) CBC hepatic and renal function

why is allopurinol started at low doses of 100mg/day

reduce hypersensitivty reaction risk and risk of causing an acute gout attack

what is AHS

allopurinol hypersensitivity reaction rare but severe - causes SJS, TEN, rash, eosinophilia this is why doses are started LOW

which ppl are particularly at risk for AHS due to HLA-B*5801 allele

koreans, han chinese, thai, african americans

BLACK BOX WARNING FEBUXOSTAT

increased risk of CV related deaths like MI, stroke compared to allopurinol thus, allopurinol should only be used in pts not responding to max dose of allopurinol, or contraindicated

febuxostat should be avoided in patients with severe ____ impairment

hepatic

dosage febuxostat

40mg QD increase to 80mg after 2 weeks if UA not below 6 -- has easier trituation than allopurinol

when would pegloticase be used

as last resort in pts with advanced gout and uncontrollable by the other ULTs reduces uric acid levels and fixes tophi

pegloticase is contraindicated in what patients

with G6PDH deficiency

true or false when using pegloticase, it takes a long time to see effects

FALSE - improves rapidly, but also very expensive

how is pegloticase given

via infusion

ppl starting pegloticase should be pretreated with what

antihistamines and corticosteroids to prevent BBW of infusion reaction also, give colchicine or NSAID for 1 week before and 6 months after treatment

role in therapy for lesinurad

used only in COMBINATION with an XO inhibitor in pts who failed on XO inhib alone

black box warning lesinurad

risk of renal failure risk decreases when given with XOI (that's why we do it)

when is lesinurad contraindicated

pts with bad renal function

dosage lesinuard

200mg QD with XOI

what is duzallo

lesinurad + allopurinol

probenecid is a ____ agent how long to see benefit? when can it NOT be started and why

uricosuric 6-12 months to see effect NOT started during an acute gout flare bc can cause more kidney stones

imp counseling pt for pts on probenecid

lot of fluids

probenecid is contraindicated in which pts

with history kidney stones or mod-severe CKD

probenecid is used as add-on therapy in what pts?

pts not reaching goal with just XOI treatment

what are fenofibrate and losartan

uricosuric agents

monitoring on probenecid

serum UA (obvious) CBC RENAL FUNCTION

what drugs decrease effects of probenecid

salicylates

outline for treating refractory gout

1. start with XOI as monotherapy. if serum UA target not achieved.... 2. ADD URICOSURIC (probenecid). if not achieved still and disease activity is continued.... 3. add pegloticase or lesinurad (RARE)1

1st and 2nd line for acute gout prophylaxis when starting ULT

1st line - colchicine 0.6mg QD or BID OR low dose NSAID (naproxen 250mg BID) BUT chronic NSAID use not rec. in older pts) 2nd line - low dose prednisone (less than 10mg a day) continue these therapies for 3-6 months AFTERRRRRRR target uric acid levels have been achieved with ULT

some nonpharm gout treatment

lose weight proper diet regular exercse limit red meats, organ meats, high fructose corn syrup, alcohol, fish, stop smoking can also ice the joint for pain relief!

true or false during gouty attacks, alcohol consumption should be totally avoided

true

alcohol intake should be limited to prevent gout flares explain what this means for men vs women

men - no more than 2 drinks a day women - no more than 1