Gout- Heeter

Underlying metabolic disorder of gout….

hyperuricemia

Inflammatory response to urate crystals in tissue is

gout

Do all patients that experience hyperuricemia experience gout?

no

Answer the following questions about the risk factors of Gout:

1. What gender is more common?

2. What age is more common?

3. A diet rich in what foods increase risk?

1. males

2. elderly

3. foods high in purines

6 risk factors of Gout:

• age- elderly

• obesity- 2x risk

• diet- purines

• lifestyle- not active

• gender- males

(can all increase serum uric acid conc)

What are some drugs that can increase uric acid levels:

• diuretics

• ethanol

• salicylates

• cytotoxics

In the acute presentation of gout, lab tests will reveal:

• elevated serum uric acid

• elevated leukocytosis

For acute gout, you most commonly see gout in the ______. and this is called _________.

• see gout in the foot

• called podagra

Patients with acute gout may also present with:

• nephrolithiasis

• gouty nephropathy

Nonpharm treatment for acute gout flares:

• reduce dietary intake of purines

• increase fluid intake

• decrease salt and sugar

• reduce alcohol intake

• exercise/lose weight

• cherry-products

• ice

What CAM therapy has been seen to reduce the risk of an acute gout attack?

cherry-containing products

(be careful w/ sugar tho)

What nonpharm treatment can be used during an acute gout attack to reduce pain?

ICE!

First line therapies for acute gout flares:

• NSAIDs

• Corticosteroids

• Colchicine

How is a first line therapy chosen for an acute gout flare?

One therapy is not more effective than the other, so chose based on comorbidities (other conditions the patient has)

What 3 NSAIDs are approved for treatment of gout?

1. Indomethacin

2. Naproxen

3. Sulindac

When experiencing an acute flare it’s important to start medication ______________.

immediately

NSAID ADRs

• GI

• Renal

• CV

• CNS

What can be used with NSAIDs to reduce GI ADRs?

• PPI

• H2RA

Answer the following about Corticosteroids:

• route

• dosing strategy of methylprednisone

• Short term ADRs

• Oral or Intraarticular injection

• Methylprednisone dose pack

• ADRS:

  • Increased Blood sugar

    • Avoid in diabetes

  • Fluid Retention

    • Avoid in uncontrolled hypertension

  • osteoporosis, glaucoma

You must reduce the dose of Colchicine if you are on _____________.

dialysis

Colchicine ADRs

• GI

  • monitor long term

• Neutropenia, Axonal Neuromyopathy

  • if patient is on statins

ACR guidelines recommend ULT therapy if the patient has:

• how many gout flares per year?

• presence of what?

• Radiologic evidence of…

• Frequent gout flares (2+ per year)

• Presence of 1+ tophi

• Radiologic evidence of gout damage

Conditional ACR recommendations for initiating Urate Lowering Therapy (ULT) include:

• 1 or more gout flares, but less than 2 per year

• 1st gout flare w/ stage 3 CKD or greater, serum uric acid >9mg/dL, or urolithiasis

If a patient is experiencing an acute gout flare, can they begin Urate Lowering Therapy?

Yes

What is the goal of Urate Lowering Therapy (ULT)?

(aka what do we what our urate levels to be)

• reduce serum urate levels to <6 mg/dL

For ULT, what is

• 1st line

• 2nd line

• 1st line- Allopurinol

• 2nd line- Febuxostat

Dosing for Allopurinol (initial and max dose)

• initial- 100 mg PO daily

titrate dose up to…

• max dose- 800mg/day

Boxed warnings for Febuxostat

• increase in all-cause mortality

• CV mortality

ADRs for Xanthine Oxidase Inhibitors

• rash

• GI

• urticaria

• For allopurinol: allopurinol hypersensitivity syndrome

Answer the following about Probenecid:

• class

• ADRs

• Drug Interactions

• Indication

• Class: uricosurics

• ADRs: increased risk of NEPHROLITHIASIS

  • make sure to maintain fluid intake

• Drug Interactions:

  • Salicylates

  • Pencillins

  • Cephalosporins

• Used as alternative when patient’s can’t use Xanthine Oxidase inhibitors or combined with Xantine Oxidase Inhibitors

Pegloticase is used…

LAST LINE for refractory treatment of gout

With what gout treatment must you discontinue all others before using?

Pegloticase

What gout treatment for ULT has a risk of infusion reactions?

Pegloticase

Pegloticase is given by IV infusion every ____ weeks for a minimum of _____ minutes.

a. 3 weeks, 130 minutes

b. 3 weeks, 120 minutes

c. 2 weeks, 130 minutes

d. 2 weeks, 120 minutes

c- given every 2 weeks for a minimum of 120 minutes

Compare Chronic versus Acute treatments of Gout

Chronic:

• For Urate Lowering Therapy (ULT)

• Xanthine Oxidase Inhibitors- 1st line

  • Allopurinol, Febuxostat

• Uricosurics

  • Probenecid

• Pegloticase

Acute:

• For acute gout flares

• NSAIDs

  • indomethacin, Sulindac, Naproxen

• Corticosteroids

  • methylprednisolone, prednisone

• Colchicine