Gout

Question 1

Drugs that Increase Uric Acid

Answer 1

• ASA, lower doses
• CNI (tacrolimus, cyclosporine)
• Diuretics (loop and thiazide)
• Niacin
• Pyrazinamide (riPe)
• Some chemo and PEP products

Question 2

Gout Risk Factors

Answer 2

• Male
• Obesity
• Excessive alcohol
• HTN
• CKD
• *Avoid organ meats, high-fructose corn syrup, alcohol**

Question 3

Acute Gout Treatment

Answer 3

• Colchicine
• Steroids
• NSAIDs
• *Choose one, continue ULT throughout**

Question 4

Colcrys

Answer 4

• Colchicine
• Dose 1.2 mg PO followed by 0.6 mg in 1 hour
• Max of 1.8 mg/hr (2.4 mg/d)
• Prophylaxis: 0.6 mg BID

Question 5

Colchicine Information

Answer 5

• CI: Don’t use P-gp or CYP3A4 inhibitor (fatal tox.)
• Warning: myelosuppression, increased myopathy risk (overdose)
• SE: Diarrhea, nausea, myopathy, neuropathy
• Start within 36 hours of sxs onset
• Wait 12 hours after tx dose to resume prophylactic dosing
• Avoid statin/fibrate (gemfibrozil) due to rhabdo risk

Question 6

NSAIDs Used for Gout Attack

Answer 6

• Indomethacin (Indocin) - taper off when done
• Naproxen (Aleve) - Q8H
• Celecoxib (Celebrex)
• *Avoid use in severe renal disease and CVD risk**

Question 7

Steroids used for Gout Attacks

Answer 7

• Prednisone
• Prednisolone
• Methylprednisolone (Medrol, Solu-Medrol) - can be oral or as an intra-articular injection if 1-2 large joints are involved
• Notes: Increase of BG/BP, insomnia, and increased appetite are to be expected w/ short-term use

Question 8

Xyloprim

Answer 8

• Allopurinol
• First-line XOI used for gout prophylaxis
• Screen those at high-risk for allopurinol allergy for HLA-B*5801 allele before use
• Titrate up dose slowly
• Target UA level < 6 mg/dL
• *Use w/ acute attack option when starting - decreases risk of attack**

Question 9

Probenecid

Answer 9

• Uricosuric: increases renal excretion of UA (need adequate kidney function)
• Second line for gout prophylaxis
• Used for XOI are CI or not tolerated OR can be added to XOI if UA isn’t at goal
• Inhibits reabsorption of UA so requires adequate renal fxn to work
• Increases B-lactam levels

Question 10

Other Prophylactic Gout Tx Options

Answer 10

• Lesinurad (Zurampic): taken with XOI if UA isn’t at goal

- Pegloticase: recombinant uricase enzyme that is used for severe, refractory disease

Question 11

Allopurinol Information

Answer 11

• Warning: allergic rxn including severe rash (test for HLA-B*5801 first), hepatotoxicity
• SE: Rash, acute gout attacks, nausea
• Use with colchicine or NSAID for first 3-6 months due to high incidence of acute gout attack
• DON’T use with mercaptopurine or azathioprine

Question 12

Uloric

Answer 12

• Febuxostat
• XOI
• Box warning: Limit use to those who can’t tolerate allopurinol due to CV risk
• Warning: hepatotoxicity and skin rxns (less rash incident compared to allopurinol)
• SE: Increased LFTs
• Use with colchicine or NSAID for first 3-6 months due to high incidence of acute gout attack

Question 13

Krystexxa Information

Answer 13

• Pegloticase - converts UA to allatoin
• Given IV Q2weeks
• Boxed warning: anaphylactic rxns (premedicate with steroids and antihistamines)
• CI: G6PD deficiency
• Do not use with XOI or probenecid (increases anaphylaxis risk)

Question 14

Elitek

Answer 14

• Rasburicase
• Urate-oxidase enzymes
• Used for Tumor Lysis Syndrome tx - (Allopurinol for prevention)
• CI: G6PD deficiency