Term
Hyperuricemia is when uric acid is above _____. It is the central feature of what gout is.
What is the reduction goal for pts with gout? |
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Definition
| >6.8 mg/dL, however, goal serum urate is usually <6ml/dL |
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Term
Put the steps of Clinical Spectrum of Gout into correct order:
a) Hyperuricemia
b)Deposits of monosodium urate crystals (tophi) in tissues in and around joints
c)Recurrent acute gouty arthritis attacks
d)uric acid nephrolithiasis
e)Interstitial renal disease |
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Definition
correct order:
a) Hyperuricemia
c)Recurrent acute gouty arthritis attacks
b)Deposits of monosodium urate crystals (tophi) in tissues in and around joints
e)Interstitial renal disease
d)uric acid nephrolithiasis |
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Term
Place these steps of Gout Stages in the correct order:
a)Asymptomatic hyperuricemia
b)Intercritical segments(intervals between flares)
c)Acute flares
d)Advanced gout |
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Definition
Gout Stages
a)Asymptomatic hyperuricemia
c)Acute flares
b)Intercritical segments(intervals between flares)
d)Advanced gout |
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Term
Which of the following are correlated with high serum uric acid concentration?
a)comorbidities like HTN, CKD, insulin resistance, hypertriglyceridemia, HTN
b)Increasing age: Peak incidence between age 30 to 50 y/o
c)Male gender
d)Postmenopausal
e)Obesity
f)Alcohol consumption
g)SCr/BUN may correlate with urate conc |
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Definition
All are factors that correlate with high uric acid level.
Men affected 7-9x > women.
However, postmenopausal women may get to same level of chance of gout attacks as men :/ |
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Term
true or false: uric acid is a waste product that serves no physiological purpose. It comes from purine degradation.
Humans lack the ________ enzyme so are unable to convert urate to more soluble form known as _______ |
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Definition
true!
Humans lack enzyme (uricase) to convert uric acid to more soluble product (allantoin) |
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Term
which of the following are not one of the three sources of uric acid?
a)Dietary purine (smallest amount)
b)Conversion of tissue nucleic acid to purine nucleotides
c)De novo synthesis of purine bases
d)allantoin reverse conversion
Average human produces ___-___mg uric acid/day; and then an extra ~___mg from diet!
true or false: all purines that become uric acid share a common metabolic pathway with nucleic acid production. |
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Definition
all are sources except d)allantoin reverse conversion.
Allantoin would not convert back to urate, I made this up.
Average human produces 600-800mg uric acid/day; and then an extra ~100mg from diet!
true: All purines enter a common metabolic pathway leading to the production of nucleic acid or uric acid |
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Term
Do people with hyperuricemia tend to be overproducers more frequently or underexcreters more frequently?
Which involves: Abnormalities in purine metabolism enzyme regulation?
Which involves Primary idiopathic hyperuricemia ?
Which will see increase in PRPP synthetase and dec in HGPRT enzyme?
Which has possible secondary causes such as certain medications and dehydration? What medications specifically? |
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Definition
80-90% are underexcreters.
10-20% are overproducers.
Overproduction: Have abnormalities in purine metabolism enzyme regulation causes overproduction.
Primary idiopathic hyperuricemia is involved with Underexcretion.
Overproduction mechanism: increase in PRPP synthetase and dec in HGPRT enzyme. Will have more production of guanine and hypoxanthine so leads to inc uric acid level.
Possible Secondary Causes of Underexcretion:
Drugs (diuretics, niacin, low-dose ASA, cyclosporine)
Most of the time drugs are just exacerbating the idiopathic reason. They are NOT CI in gout, so don’t necessarily want to stop their med but can see what tipped them over the edge to have gouty attack.
Dehydration is also secondary cause
Due to dec clearance of uric acid |
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Term
Which of the following are conditions that can contribute to hyperuricemia from overproduction due to increased breakdown of tissue nucleic acids & excessive rates of cell turnover?
a)Myeloproliferative/lymphoproliferative disorders
b)Polycythemia vera
c)Psoriasis
d)Some types of anemias
e)all of the above |
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Definition
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Term
Which of the following drugs can be a secondary cause of underexcretion?
a)diuretics
b)niacin
c)methotrexate
d)low-dose ASA
e)cyclosporine |
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Definition
all except methotrexate!
Possible Secondary Causes
Drugs (diuretics, niacin, low-dose ASA, cyclosporine).
Most of the time drugs are just exacerbating the idiopathic reason. They are NOT CI in gout, so don’t necessarily want to stop their med but can see what tipped them over the edge to have gouty attack.
Dehydration is also secondary cause
Due to dec clearance of uric acid |
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Term
For determining overproduction or underexcretion:
Infrequently but ideally: Purine-free diet x ___ days
Then get a 24 hr urine uric acid measurement
>___mg uric acid excreted--> overproducers
<___mg uric acid excreted-->underexcreters
More common practice: Regular diet
> ___mg in urine per 24 hrs --> overproduction
< ___mg in urine --> ‘normal’
< ___mg in urine --> pt is considered to be an ‘underexcreter’ |
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Definition
Infrequently but ideally:
Purine-free diet x 3-5 days
Then get a 24 hr urine uric acid measurement
> 600mg uric acid excreted--> overproducers
< 600mg uric acid excreted--> underexcreters
More common practice:
Regular diet
> 1000mg in urine per 24 hrs overproduction
< 1000mg in urine ‘normal’
< 800mg in urine pt is considered to be an ‘underexcreter’ |
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Term
Which of the following sx are associated with:
Classic acute gout (aka 'podagra')?
Interval or intercritical gout?
Tophaceous gout?
Atypical gout?
Renal effects?
a)fever
b)with or without hyperurecemia
c)lasts 3-14 days
d)takes 10+ yrs to develop
e)elderly: can be in upper extremities.
f)asymptomatic period between attacks
g)Deposits of monosodium urate crystals in soft tsus. complications include soft-tsu damage, deformity, joint destruction, and verve compression syndromes such as carpal tunnel
h)polyarthritis affecting any joint, upper or lower extremity. may be confused with RA or osteoarthritis.
i)Nephrolithiasis. Acute and chronic gouty nephropathy. |
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Definition
Classic acute gout (aka 'podagra'): Fever, with or without hyperuricemia, lasts 3-14 days
Interval or intercritical gout: asymptomatic period between attacks
Tophaceous gout: takes 10+ yrs to develop. Deposits of monosodium urate crystals in soft tsus. complications include soft-tsu damage, deformity, joint destruction, and verve compression syndromes such as carpal tunnel
Atypical gout: elderly; can be in upper extremities. polyarthritis affecting any joint, upper or lower extremity. may be confused with RA or osteoarthritis.
Renal effects: Nephrolithiasis. Acute and chronic gouty nephropathy. |
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Term
| why does monoarticular arthritis happen in extremities? |
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Definition
| bc extremities have lower temp so more likely to have uric acid crystallization here. |
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Term
__Definitive/Alternative__ Diagnosis can be described as follows:
a)Aspiration of synovial fluid from affected joint.
b)Identify negative birefringent monosodium urate crystals in synovial fluid leukocytes
c)Usually not done bc pt in pain already. If suggested, usually pt doesn’t want it done. Would have to inject and get out synovial fluid to see the crystals |
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Definition
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Term
__Definitive/Alternative__ Diagnosis can be described as follows:
Clinical Triad
1)Inflammatory monoarthritis (esp if in big toe)
2)Elevated uric acid level (do not treat is hyperurecemia but no sx…)
3)Response to colchicine
Limits
-Failure to recognize atypical gout
-Serum uric acid levels normal 50% of the time |
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Definition
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Term
Which complication of gout is related to: More acidic urine-->less-soluble uric acid
a)Nephrolithiasis
b)Gouty nephropathy
c)Tophaceous gout |
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Definition
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Term
Which complication of gout is related to:
Acute: result of blockage of urine flow secondary to massive uric acid crystal precipitation
Chronic: long-term renal urate crystal deposition
a)Nephrolithiasis
b)Gouty nephropathy
c)Tophaceous gout |
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Definition
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Term
Which complication of gout is related to: late complication, can be in many parts of body.
Great toe, helix of ear, Achilles tendon, knees, wrists, hands (Rare: hips, shoulders, spine).
Joint destruction, pain, and nerve compression --> Severe amt of pain
a)Nephrolithiasis
b)Gouty nephropathy
c)Tophaceous gout |
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Definition
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Term
what drugs can be used for ACUTE gouty arthritis? which can also be used for prophylaxis?
a)NSAIDs
b)Colchicine
c)Corticosteroids
d)allopurinol |
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Definition
| all except allopurinol are for ACUTE. Colchicine can be used as either ACUTE or for PROPHYLAXIS |
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Term
which of the following drugs is FDA approved for acute gout attacks?
a)ibuprofen
b)Indomethacin (Indocin)
c)Naproxen (Naprosyn)
d)Sulindac (Clinoril)
which of these is used most often? |
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Definition
NSAIDs are mainstay of therapy for acute attacks. Excellent efficacy + minimal toxicity (when used short-term)
all except ibuprofen are FDA approved for acute gout attacks.
which is used most often? ibuprofen
**Not FDA approved: ibuprofen. Works great and the most often!! |
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Term
What are the most important points for therapeutic success when using NSAIDs for acute gout?
a)Initiate at onset of symptoms
b)Initiate at maximum doses --> continue 24 hrs after resolution--> taper/titrate quickly over 2-3 days
c)start at low dose and taper up
Sx resolve in ___ days instead of 3-14 days. So wont stop attack right away but will help. |
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Definition
a and b are the most important points. NOT c (it's false)!
Sx resolve in 3-5 days instead of 3-14 days. So wont stop attack right away but will help. |
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Term
Dose for indomethacin, naproxen, sulindac, ibuprofen for acute gouty attack?
a)800mg po QID
b)200mg po BID x 7-10 days
c)500mg po BID x 3 days, then 250mg-500mg po daily x 4-7 days
d)25-50mg po QID x 3 days, then taper to BID x 4-7 days |
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Definition
Start at max dose and then titrate down
Indomethacin:25-50mg po QID x 3 days, then taper to BID x 4-7 days
Naproxen:500mg po BID x 3 days, then 250mg-500mg po daily x 4-7 days
Sulindac:200mg po BID x 7-10 days
Ibuprofen:800mg po QID |
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Term
which of the following are AEs of NSAIDs?:
a)GI (gastritis, bleeding, perforation)
b)Renal (necrosis, ↓CrCl)
c)CV (Na & fluid retention, ↑BP)
d)CNS (impaired cognition, HA, dizziness) |
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Definition
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Term
When using NSAIDs for acute gout, caution should be heeded in which hx dz states:
a)PUD
b)CHF
c)Uncontrolled HTN
d)Renal insufficiency
e)CAD
f)Anticoagulants
g)PID |
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Definition
| all of the above except PID |
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Term
Which of the following are CONTRAINDICATED for use of NSAIDs for acute gout?
a)Active PUD
b)Active bleeding
c)Uncompensated CHF
d)Severe renal impairment
e)Hypersens. to ASA or any NSAID |
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Definition
all are CI
Consider concomitant PPI in those at risk for GI bleed. |
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Term
which of the following are TRUE of colchicine?
a)Reserved: If there is a CI, intolerance, or unresponsive to NSAIDs
b)Anti-mitotic: Prevents the activation, degranulation, and migration of neutrophils thought to mediate some gout symptoms
c)Highly effective
d)But have the Lowest benefit/toxicity ratio (should be careful of dosages, esp with the new FDA approved brand name agent)
e)Must initiate within 48 hours of symptoms The sooner, the better
f)Don’t use colchicine if pt has had it longer than 48hrs, will be ineffective!
g)But you CAN use NSAIDs beyond initial 48hrs. Still want to use it sooner than later |
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Definition
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Term
true or false: Colchicine has significant (23% of pts) GI adverse effects such as dose-dependent N/V/D.
true or false: Colchicine has
Neutropenia, axonal neuromyopathy as adverse effects.
Treatment of Gout FLARES: ___mg at the first sign of a gout flare followed by ___mg one hour later.
Max over one hour: ___mg
Max over 24hrs: ___mg
If pt has CrCl < __mL/min and/or severe hepatic impairment: no adjustment but do not repeat course for at least __ weeks.
So if pt has no hepatic or renal issues then CAN repeat this dose every __ days!
Note: there is a different dose regimen for PROPHYLAXIS |
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Definition
true and true.
Treatment of Gout Flares: 1.2 mg (two tabs) at the first sign of a gout flare followed by 0.6 mg one hour later.
Max over one hour: 1.8mg
Max over 24hrs: 2.4mg
If pt has CrCl < 30 mL/min and/or severe hepatic impairment: no adjustment but do not repeat course for at least 2 weeks
So if pt has no hepatic or renal issues then CAN repeat this dose every 3 days!
Used to be dosed everyday but not anymore bc toxicity. It’s very effective so most pts wont need it everyday. |
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Term
which drug has Neutropenia, axonal neuromyopathy as adverse effects?
which drug has seen deaths from agranulocytosis?
which drug should not be taken with macrolides (especially clarithromycin)?
with which drug will strong CYP3A4 inhibitors interact? do we need to adjust dose?
With which drug will there be an ABSOLUTE CONTRAINDICATION if patient has BOTH [Renal or Hepatic impairment] with [P-gp or strong CYP3A4 inhibitor]? |
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Definition
colchicine is answer for all! also dose dependent N/V/D in 23% of pts
Strong CYP3A4 Inhibitors will also interact. Yes dosage adjustment is necessary (see package insert table)
Contraindication: [Renal or hepatic impairment] + [P-gp or strong CYP3A4 inhibitors]--> will develop life-threatening or fatal colchicine toxicity |
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Term
which of the following is NOT true about corticosteroids?
a)they are reserved for pts that are CI, intolerant to, or unresponsive to NSAIDs and colchicine
b)may be good if polyatricular involvement
c)can be given as systemic (Oral) or IM or as Intraarticular injection
d)corticotropin (ACTH) is likely to be used
e)they should not be used long term bc of multiple adverse effects. Osteoporosis, HPA suppression, cataracts, muscle deconditioning
f)caution in pts with diabetes. Monitor closely in pts with GI problems, bleeding disorders, CV dz, psychiatric disorders
g)
Dosage for oral use:
___-___mg of a prednisone-equivalent daily x __-__ days, then taper in 5mg increments over __-__ days until d/c.
Taper is necessary to prevent rebound flare-up |
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Definition
all except d) are true.
Reserved for pts with CI, intolerance, or unresponsive to NSAIDs & colchicine
Polyarticular involvement may benefit
Systemic Oral: 30-60mg prednisone-equivalent daily x 3-5 days, then taper in 5mg increments over 10-14 days until d/c
Taper necessary to prevent rebound flare-up
IM: triamcinolone x 1 dose; methylprednisolone x 1-2 days
Intraarticular injection: triamcinolone
If pt has ONE joint affected, more likely to see one injection of this drug. But if multiple then can use systemic CCS. Outpatient injection, can go to primary care doctor
Corticotropin (ACTH): limited data; difficult to obtain in U.S. Sometimes used. COULD use it for acute gouty attack but probably unlikely to use it |
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Term
| if used long term, which class of drugs may result in Osteoporosis, HPA suppression, cataracts, muscle deconditioning? |
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Definition
| corticosteroids. avoind long term use! also caution in diabetics. |
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Term
when it comes to prophylactic therapy for gout, if pt currently has an acute attack, how long should we wait to give prophylaxis?
Which of the following pts should NOT receive prophylaxis?
a)Mild first episode and responded to treatment
b)Serum urate minimally elevated
c)24hr urinary uric acid excretion <1000mg with regular diet |
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Definition
Must wait 6-8wks AFTER resolution
all three grps of pts should not receive prophylaxis. Wait and see. Some pts never have a 2nd attack! |
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Term
which of the following are reasons to use prophylaxis therapy for gout?
a)Severe attack
b)Complicated course of uric acid nephrolithiasis (dx progressed)
c)Serum urate > 10 mg/dL (if this high, they have significant increase risk of attack so may want to consider prophylaxis)
d)24 hr urinary uric acid excretion > 1000mg
e)Tophi are present (complicated, extended, prolonged version of gout) |
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Definition
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Term
which of the following drugs are options for prophylaxis?
a)Colchicine
b)NSAIDs
c)Allopurinol (Zyloprim)
d)Febuxostat (Uloric)
e)Probenecid
f)Sulfinpyrazone
which will decrease synthesis of uric acid?
which will increase urinary excretion so is ONLY for underexcreters (80-90% of pts)? |
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Definition
all except NSAIDs are used as prophylaxis
1. Colchicine
Xanthine Oxidase Inhibitors
2. Allopurinol (Zyloprim)
3. Febuxostat (Uloric)
will decrease synthesis of uric acid
Uricosurics
3. Probenecid
4. Sulfinpyrazone
Increase urinary excretion, so only for
underexcreters, 80-90% of pts, but still
don’t normally check if they are
underexcreters or overproducers |
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Term
what is the dosage regimen for colchicine used for PROPHYLAXIS?
___mg __ x daily in 16 years of age or older. Max: ___ mg/day.
If pt has CrCl < 30mL/min: then can do ___mg/day, closely monitor if dose increase |
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Definition
Prophylaxis: 0.6 mg once or twice daily in 16 years of age or older. Max: 1.2 mg/day.
If pt has CrCl < 30mL/min: then can do 0.3mg/day, closely monitor if dose↑
Note: this is different than colchicone used for acute gout flares, which is:
Treatment of Gout Flares: 1.2 mg (two tabs) at the first sign of a gout flare followed by 0.6 mg one hour later.
Max over one hour: 1.8mg
Max over 24hrs: 2.4mg
If pt has CrCl < 30 mL/min and/or severe hepatic impairment: no adjustment but do not repeat course for at least 2 weeks
So if pt has no hepatic or renal issues then CAN repeat this dose every 3 days!
Used to be dosed everyday but not anymore bc toxicity. It’s very effective so most pts wont need it everyday. |
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Term
true or false:
Colchicine for prophylaxis is best used in patients with no evidence of tophi and normal or slightly elevated serum urate.
No resistance or tolerance develops
may Consider d/c colchicine when Serum urate within normal range AND Symptom-free x 1 year
Can initiate colchicine with urate-lowering therapy for 6-12 months to prevent acute attack. |
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Definition
true!
colchicine for prophylaxis is best used in patients with no evidence of tophi and normal or slightly elevated serum urate (because colchicine does not lower uric acid level like other meds do)
Consider d/c colchicine when Serum urate within normal range AND Symptom-free x 1 year
NOTE: Can initiate colchicine with urate-lowering therapy for 6-12 months to prevent acute attack.
There are other prophylatic meds, even if wait 6-8wks may still cause gouty attack (by lowering uric acid, and ANY fluctuation in urate can cause attack, so give with urate-lowering meds along with colchicine or NSAID to get them through 6 months. Depending on tolerance! |
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Term
which drug used for prophylaxis is Efficacious for both underexcretors and overproducers?
which is most widely prescribed?
which is dose-dependent lowering of uric acid?
which promotes shrinkage of tophi?
which has multiple labeled indications (such as mgmt of recurrent calcium oxalate calcili)? |
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Definition
Allopurinol is the answer for all!
Efficacious for both underexcretors and overproducers: Allopurinol, |
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Term
true or false: Allopurinol has an INACTIVE metabolite known as oxypurinol.
standard regimen for allopurinol? max dose? |
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Definition
false, oxypurinol is an ACTIVE metabolite.
therefore, allopurinol as long half life and can dose once daily.
Start at 100mg/day; increase 100mg/day q week.
Available as 100mg, 300mg tablets
Maintenance dose: 100-300mg/day
Tophaceous gout: 400-600mg/day
Max: 800mg/day
Excretion via glomerular filtration so is a problem with pts with renal issues. Start with 100mg, can increase weekly. Etc. keep pushing until <6 or until pt gets SE |
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Term
| which of the following are false about allopurinol? a)5% cannot tolerate b)Mild AEs: Skin rash, leukopenia, GI problems, HA, urticaria c)Severe AEs: “allopurinol hypersensitivity syndrome” (included in the 5% that cant tolerate it.) Also Hepatitis, interstitial nephritis, eosinophilia! d)Warfarin interaction. May decrease anticoagulant effect e)$100/yr... Pretty cheap |
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Definition
| all are true except d). correct statement is that allopurinol may ENHANCE the anticoagulant effect. adjust warfarin dose |
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Term
which of the following are advantages of Febuxostat over allopurinol?
a)Not reported to cause hypersensitivity rxns :)
b)Dosage titration less complex (is also once daily dosing)
c)No dosage adjustment with mild-mod renal impairment. Just Caution if <30mL/min (just have to monitor pt)
which of the following are disadvantages?
a)Limited labeled indications
b)CI: tx with xanthine oxidase substrates (such as w/ azathioprine. Allopurinol has warning or precaution whereas febuxostat has CI)
c)Increased CV thromboembolic events? May see this more now that drug is out on market
d)Possible increased LFTs, so monitor at 2 & 4 months |
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Definition
all are true.
also know that allopurinol and febuxostat are both xanthine inhibitors and used for BOTH underexcreters and over producers |
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Term
which of the following are false about febuxostat?
a)Common Aes: Nausea, arthralgia, rash, ↑transaminases (6%)
b)Available: __mg and __mg tablets
c)Initially __mg once daily; inc to __mg if serum uric acid not < 6 mg/dL
d)Option for allopurinol-intolerant patients but is $2000/yr and Brand name only |
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Definition
all are true
c)Initially 40mg once daily; inc to 80mg if serum uric acid not < 6 mg/dL
Note: 80mg more effective than 300mg allopurinol (However, 300mg is not max dose of allopurinol, Depends on pt and what their uric acid level is) |
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Term
which two drugs work by increasing renal clearance by inhibiting postsecretory reabsorption of uric acid?
which drugs are used ONLY with documented UNDEREXCRETION?
true or false: with these drugs you start low and go slow
out of these two which is used more often? why?
which drugs have:
Major Aes: GI irritation, rash, hypersensitivity, gouty flare, stone formation
Interactions: Salicylates interfere with mechanism, leads to treatment failure. Also, increases plasma conc. of penicillins, cephalosporins, sulfonamides, indomethacin.
CI in patients with CrCl < __ mL/min, or if have renal calculi history, overproducers |
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Definition
Probenecid & Sulfinpyrazone
increase renal clearance by inhibiting postsecretory reabsorption of uric acid
Used ONLY with documented underexcretion (DON’T work in overproducers)
< 800mg urate in 24 hrs with regular diet
Dose: Start low, go slow <--main thing with these.
Probenecid used more than sulfinpyrazone. Less SEs and better tolerated
Major Aes: GI irritation, rash, hypersensitivity, gouty flare (when going thru initial period of starting the med, can have gouty flare with any of the gout drug from fluctuations), stone formation
Interactions: Salicylates interfere with mechanism, leads to treatment failure. Also, increases plasma conc. of penicillins, cephalosporins, sulfonamides, indomethacin
CI in patients with CrCl < 50 mL/min, or if have renal calculi history, overproducers |
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Term
what drug is indicated ONLY for treatment of chronic gout in adults REFRACTORY to conventional therapy? For pts who have tried EVERYTHING and have severe attacks and affecting their QOL?
what is the dosage?
any contraindications?
any precautions? |
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Definition
Pegloticase (Krystexxa)
injection of recombinant uricase (enzyme that breaks down uric acid into soluble form)
Dosing: 8mg given as an IV infusion over >120 minutes every 2 weeks (optimal tx duration has not been established). Patient will go to infusion center q 2 weeks.
Contraindication: G6PD Deficiency. Don’t necessarily need to screen for this but if u know about it then don’t give this med..
Precautions:
1)Anaphylaxis/Infusion Rxn: manifests within 2 hrs; pre-medicate with antihistamines/corticosteroids; monitor closely and slow infusion down or stop if occurs
2)Gout Flares: Do not need to d/c if have flare while taking, same with other prophylactic meds. Can continue even if get attack while already on it. But don’t want to START within 6-8wks of pt’s last attack!
Use NSAID prophylaxis for first 6 months unless contraindicated or cannot tolerate
3)CHF: exacerbated in select patients |
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Term
which drugs can cause:
anaphylaxis?
infusion reactions? |
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Definition
anaphylaxis? pegloticase
infusion reactions? pegloticase |
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Term
which of the following is not a COMMON AE of pegloticase?
Anaphylaxis/Infusion Reactions
Gout Flares (more common in first __ months)
Nausea/Vomiting
Contusion or ecchymosis
Constipation
Chest Pain
Immunogenicity
Also, is dose adjustment needed for renal impairment? hepatic impairment? |
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Definition
unfortunately, these are ALL common AEs of pegloticase!
No dose Adjustment required for renal impairment
Not studied in hepatic impairment (so DON’T use in these pts just yet) |
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Term
which of the following are NOT important patient education points about pegloticase?
Patient Education
Anaphylaxis/Infusion rxns can occur at any time during therapy
Stress importance of adherence to prophylactic medication
Educate on s/s of anaphylaxis
Wheezing, rash, peri-oral or lingual edema, urticaria, hemodynamic instability
Do not stop if patient experiences gout flares. |
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Definition
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Term
In order to be considered for pegloticase, patient must hit all three of these criteria EXCEPT:
1)Baseline serum uric acid of _+ mg/dL
2)Symptomatic gout with __ or more gout flares in the previous 18 months
Or
at least _ gout tophus or gouty arthritis
3)Self-reported contraindication to allopurinol
Or
medical history of failure to normalize uric acid (<6 mg/dL) with __+ months of allopurinol treatment at the maximum dose
true or false: pegloticase may possibly have a role as bridging therapy. |
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Definition
1)Baseline serum uric acid of 8+ mg/dL
2)Symptomatic gout with 3+ (3 or more) gout flares in the previous 18 months
Or
at least 1 gout tophus or gouty arthritis
3)Self-reported contraindication to allopurinol
Or
medical history of failure to normalize uric acid (<6 mg/dL) with 3+ months of allopurinol treatment at the maximum dose
true: Possible important role as a bridging therapy. ~ 6 month duration in severe treatment refractory gout. Once urate levels have been controlled, other antihyperuricemic medications can be restarted to maintain urate balance |
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Term
what are some miscellaneoue agents for gout?
a)fenofibrate
b)losartan
c)valsartan
d)all of the above
Which drug applies?:
Ancillary benefit by decreasing clearance of hypoxanthine and xanthine, thus sustained reduction in serum rate
20-30% reduction in acute attacks (also see dec in uric acid)
Inhibits renal tubular reabsorption of uric acid, thus increases urinary excretion
Alkanizes urine thus decreased stone formation
Does not appear to cause an acute flare
Good option for pts with TG issues and gouty attacks |
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Definition
just fenofibrate and losartan.
Fenofibrate
Ancillary benefit by decreasing clearance of hypoxanthine and xanthine, thus sustained reduction in serum rate
20-30% reduction in acute attacks (also see dec in uric acid)
Does not appear to cause an acute flare
Good option for pts with TG issues and gouty attacks
Losartan
Inhibits renal tubular reabsorption of uric acid, thus increases urinary excretion
Alkanizes urine thus decreased stone formation
Unique property of losartan (vs. other ARBs)...If pt on ARB, need prophylactic therapy for gout, can try to switch to losartan! |
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Term
which of the following has high purine content and should be avoided by patients with gout:
a)High saturated fats
b)Red meats/shell fish
c)Alcohol (Beer>spirits>wine)
d) High fructose corn syrup )Soft drinks, energy drinks)
e) fruit loops
what are other nonpharm options? |
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Definition
all except fruit loops
other nonpharm options:
-Weight loss
-Joint rest x 1-2 days
-Local application of ice
fyi: But generally lower temp in extremities is reason for gout to happen. But if already have attack then ice wont worsen their gouty attack |
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Term
what lab things need to be measured at baseline in patients with gout?
a)Renal & hepatic function
b)CBC
c)electrolytes
d)serum uric acid levels
for Prophylaxis treatment:
Generally monitor every week to 3 week to see if uric acid level is <6, titrate drug accordingly
Recheck baseline labs q __-__ months after pt has reached <6 level.
Because increase comorbidities, pt should be evaluated for _____ disease. |
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Definition
all except serum uric acid levels.
Serum uric acids levels monitored during dose titration phase until < 6 mg/dL
Because increase comorbidities, pt should be evaluated for CV disease |
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Term
which of the following are correctable causes of gout?
a)Diuretics
b)niacin
c)obesity
d)malignancy
e)alcohol abuse |
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Definition
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Term
| If acute gouty attack, and no CI to NSAIDs, then use NSAIDs. But if there IS a CI, use colchicine if within 48hrs. If not within 48hrs, then consider systemc CCS if mult joints, or just one intraarticular injection of triamcinolone if has one joint affected |
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Definition
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Term
which drug has contraindication for the following:
a)G6PD deficiency
b)[Renal or hepatic impairment] + [P-gp or strong CYP3A4 inhibitors]
c)diuretics, niacin, low-dose ASA, cyclosporine |
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Definition
a)G6PD deficiency: pegloticase
b)[Renal or hepatic impairment] + [P-gp or strong CYP3A4 inhibitors]: COLCHICINE
c)diuretics, niacin, low-dose ASA, cyclosporine: these drugs are NOT CI with any gout meds, but may still contribute to gout |
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Term
which drug has contraindication for the following:
d)Active PUD, Active bleeding, Uncompensated CHF, Severe renal impairment, Hypersens. to ASA or any NSAID
e)treatment with xanthine oxidase substrates (azathioprine)
f)patients with CrCl < 50 mL/min, or if have renal calculi history, overproducers |
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Definition
d)Active PUD, Active bleeding, Uncompensated CHF, Severe renal impairment, Hypersens. to ASA or any NSAID: NSAIDs (Consider concomitant PPI in those at risk for GI bleed)
e)treatment with xanthine oxidase substrates (azathioprine): FEBUXOSTAT
f)patients with CrCl < 50 mL/min, or if have renal calculi history, overproducers: PROBENECID and SULFINPYRAZONE |
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Term
| CHF exacerbated by which drugs? |
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Definition
pegloticase (it's a precaution)
NSAIDs (it's a caution or CI if CHF is uncompensated) |
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Term
| which drug(s) has common AE of contusion or ecchymosis? how about chest pain?! costipation? immunogenicity? gout flares within first 3 motnhs? anaphylaxis or infusion rxn? |
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Definition
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Term
| which gout med has AEs of CNS effects? Na and fluid retention and thus BP increase? renal necrosis or dec CrCl? Gastritis? |
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Definition
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Term
| which gout drug must be initiated within 48hrs of sx onset or else it will be ineffective? |
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Definition
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Term
| which drug has adverse event of GI dose-dependent N/V/D? |
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Definition
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Term
| which drug has adverse event called Neutropenia or axonal neuromyopathy? |
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Definition
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Term
| which drug should NOT be used with macrolides? |
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Definition
colchicine
Mainly bc biliary excretion of colchicine may be reduced increased conc. of colchicine |
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Term
| with what drug will strong CYP3A4 inhibitor interact? dosage adjustment needed? |
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Definition
| colchicine. yes, must adjust |
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Term
| which drug Promotes shrinkage of tophi? |
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Definition
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Term
| which drug has indications for: Chronic gout, chemotherapy causing ↑uric acid, management of recurrent calcium oxalate calculi |
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Definition
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Term
| which drug is excreted via glomerular filtration,thus has severe AEs such as Hepatitis, interstitial nephritis, eosinophilia? |
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Definition
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Term
| which drug may interact with warfarin? what will it do to warfarin? |
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Definition
| allopurinol, will enhance anticoag effect |
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Term
which drug has mild AEs:
Skin rash, leukopenia, GI problems, HA, urticaria |
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Definition
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Term
| what drug has a severe AE that is a hypersensitivity syndrome? |
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Definition
allopurinol
“allopurinol hypersensitivity syndrome” |
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Term
| which drug may possibly increase LFTs? must Monitor at __ and __ months |
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Definition
febuxostat.
Monitor at 2 & 4 months |
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Term
Many drugs have problems associated with low CrCl, which drugs apply to the following:
Caution < 30mL/min:
CrCl < 50 mL/min:
May decrease CrCl:
Adjust dose according to CrCl: |
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Definition
Caution < 30mL/min: colchicine for acute (no adjustment needed but dont give again for 2 weeks. also if has hepatic issues). colchicine for prophylaxis (then can do 0.3mg/day, closely monitor if dose inc)
CrCl < 50 mL/min: CI with uricosurics (probenecid and sulfinpyrazone). also CI if have renal calculi history, overproducers.
May decrease CrCl: NSAIDs
adjust dose according to CrCl: with allopurinol. there is a whole chart. |
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Term
| which drug(s) do you Dose: Start low, go slow |
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Definition
| Uricosurics: Probenecid & Sulfinpyrazone |
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Term
which drugs have these interactions:
Salicylates interfere with mechanism, leads to treatment failure. Also, increases plasma conc. of penicillins, cephalosporins, sulfonamides, indomethacin |
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Definition
| Uricosurics: Probenecid & Sulfinpyrazone |
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Term
| true or false: these are sx of anaphylaxis rxn (Wheezing, rash, peri-oral or lingual edema, urticaria, hemodynamic instability) and are associated with this drug? |
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Definition
true. pegloticase
Anaphylaxis/Infusion rxns can occur at any time during therapy. Stress importance of adherence to prophylactic medication
Do not stop if patient experiences gout flares |
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Term
| which drug has three requirements, with one being baseline serum uric acid of 8mg/dL or more |
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Definition
pegloticase
1)Baseline serum uric acid of 8+ mg/dL
2)Symptomatic gout with 3+ (3 or more) gout flares in the previous 18 months
Or at least 1 gout tophus or gouty arthritis
3)Self-reported contraindication to allopurinol
Or medical history of failure to normalize uric acid (<6 mg/dL) with 3+ months of allopurinol treatment at the maximum dose |
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Term
| which drug has Possible important role as a bridging therapy ? |
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Definition
pegloticase
Possible important role as a bridging therapy
~ 6 month duration in severe treatment refractory gout
Benefits vs. Risks
Once urate levels have been controlled, other antihyperuricemic medications can be restarted to maintain urate balance |
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Term
which miscellaneous agent:
Does not appear to cause an acute flare
Alkanizes urine thus decreased stone formation |
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Definition
fenofibrate:Does not appear to cause an acute flare
losartan: Alkanizes urine thus decreased stone |
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