Gout

Question 1

What is Gout?

Answer 1

• type of Arthritis caused by a build up of uric acid in the joints (uric acid is made from purine synthesis metabolisim - later card)

Question 2

In what location of the body does gout normally attack at?

Answer 2

• Metatarsophalangeal joint or the Big Toe Joint

Question 3

What are some risk factors for Gout?

Answer 3

• Male
• Obesity
• Excessive alcohol (i.e.; Beer)
• Hypertension
• CKD
• Elderly
• Medications (another slide)

Question 4

What medications can increase uric acid in the body resutling in possible Gout?

Answer 4

• Aspirin (low doses)
• Cyclosporine
• Diuretics (loops and Thiazides)
• Niacin
• Pyrazinamide

Question 5

What are some foods that should be avoided if you are prone to having gout flares?

Answer 5

• Organ Meats
• High Fructoce Corn Syrups
• Alcohols

Question 6

What are some foods that someone that is prone to gout flares should eat in moderation?

Answer 6

• Fruit Juices
• Table Sugar
• Sweetened Drinks (i.e., sodas)
• Desserts (i.e, bad fats)
• Salts
• Lamb, Pork, Beef, Seafoods with high purine (i.e., sardines or shelled fishes)

Question 7

What are some treatment options to help with the acute gout attacks?

Answer 7

• Colchicine (colcrys) (DO NOT use when CrCl < 30)
• NSAIDs (Could cause more renal issues)
• Steroids (most common due to safety)
• Interleukin-1 Antagonists [For those that cant tolerate the other 3 options here]

Question 8

what are some treatment options to help with chronic gout attacks?

Answer 8

• Allopurinol or Febuxostat (XOI)

Question 9

What are some treatment options when XOI do not work & UA > 6?

Answer 9

• + Probenecid to XOI
• Replace XOI with IV Pegloticase

Question 10

What is the initial dosing for colchicine for gout?

Answer 10

• 1.2 mg PO (Two 0.6 mg tabs) followed by 0.6 mg PO 1 hour later

Question 11

What are some contraindications for Colchicine used for Gout?

Answer 11

• DO NOT use with P-gp or 3A4 Inhibitors with renal and/or hepatic impairment (Fatal Toxicity)

Question 12

What are some warnings for colchicine used for Gout?

Answer 12

• Myelosuppression
• Increased Myopathy Risk (when taking with: cycolsproine, diltiazem, verapamil, gemdibrozil, statins)

Question 13

What are some side effects for colchicine used for Gout?

Answer 13

• Diarrhea, Nausea, Myopathy, Neuropathy (dose limiting), decreased Vit B12
• Rash?

Question 14

What are some additional notes for Colchicine used for Gout?

Answer 14

• Start within 36 hours of symptom onset
• Wait 12 hours after treatment before resuming prophylaxis dosing

Question 15

What are some NSAIDs that are used for Gout?

Answer 15

• Indomethacin (Indocin)
• Naproxen (Aleve)
• Celecoxib (Celebrex)

Question 16

What are some additional notes for NSAIDs used for Gout?

Answer 16

• Avoid use in severe renal disease and CVD risk
• Other NSAIDs can be used too

Question 17

What are some Steroids that are used for gout?

Answer 17

• Prednisone/Prednisolone
• Methylprednisolone (Medrol, Solu-Medrol)

Question 18

What is important to know about the dosing for Methylprednisolone Injections for gout?

Answer 18

• use if 1-2 joints are involved
• May cause joint damages if used repeatly in the same joint

Question 19

What are some additional notes for steroids used for Gout?

Answer 19

• Increases BG, BP, Insomnia, Appetite
• Can be PO, IM, IV, Intra-articular (if 1-2 joints)

NO adrenal suppression? but it does sooooo

Question 20

What are some of the prophylactic treatment options for gout?

Answer 20

• Colchicine, NSAIDs, Steroids (reduce risk of attacks)
• Allopurinol (1st line)
• +/- Probenecid
• +/- Pegloticase

Question 21

What is the way that uric acid/gout forms within the body?

Answer 21

• Adenosine –> Hypoxanthine –xanthine oxidase–> Xanthine –xanthine oxidase–> Uric Acid (–> allantoin or renal clearence) = GOUT

Question 22

What is the MOA for Allopurinol?

Answer 22

• Blocks xanthine oxidase from producing Uric Acid and makes a non-toxic end product

Question 23

What are some warnings for allopurinol used for Gout?

Answer 23

• Hypersensitivity reactions (severe rash): need to get HLA-B * 5801 testing before using (esp. in asian descent, african americans…) and DO NOT use if positive
• Hepatotoxicity

Question 24

What are some side effects for allopurinol used for Gout?

Answer 24

• Rash, Gout flare, Nausea, Increased LFTs (liver injury possibly)

Question 25

What are some **additional notes** for **allopurinol** used for **Gout**?

Answer 25

- **Titrate dose up** until UA level are **< 6** - Due to **gout flare**, **Colchicine or NSAIDs** are given for the first **3 - 6 months**

Question 26

What are some **boxed warnings** for **febuxostat** used for **Gout**?

Answer 26

- **Increased CV death** compared to those taking allopurinol; should limit to those that **cant tolerate allopurinol**

Question 27

What are some **warnings** for **febuxostat** used for **Gout**?

Answer 27

- Hepatotoxicity - Serious skin reactions

Question 28

What are some **side effects** for **febuxostat** used for **Gout**?

Answer 28

- Rash, Nausea, **increased LFTs**, Arthralgia

Question 29

What are some **additional notes** for **febuxostat** used for **Gout**?

Answer 29

- Due to **Gout flare**; **Colchicine or NSAIDs** are given for the first **3 - 6 months** - Can be used when **allopurinol** is contraindicated due to the **HLA-B * 5801 +**

Question 30

What is the **MOA** of **probenecid** ?

Answer 30

- Inhibits reabsorption of uric acid in the kidneys = **incresing excretion**

Question 31

What is important to know about the **dosing** of **Probenaicd**?

Answer 31

- **AVOID** in those with **CrCl < 30**

Question 32

What are some **additional notes** for **prodenecid** used for **Gout**?

Answer 32

- Can help **increase beta-lactam levels** (Drug-drug interactions)

Question 33

What is the **MOA** of **Pegloticase**?

Answer 33

- **converts** uric acid to **allantoin** which gets excreted

Question 34

What are some **Boxed warnings** for **pegloticase** used for **Gout**?

Answer 34

- **Anaphylactic Reactions** (premedicate with Antihistamines & steroids)

Question 35

What are some **contraindications** for **pegloticase** used for **Gout**?

Answer 35

- G6PD Deficiency

Question 36

What are some **additional notes** for **pegloticase** used for **Gout**?

Answer 36

- DO NOT use with allopurinol, febuxostat or probenecid

Question 37

What are some of the **Drug interactions** for **Xanthine Oxidase Inhibitors**?

Answer 37

- **DO NOT** use with Mercaptopurine or Azathioprine with Febuxostat - **AVOID** use with Pegloticase