Gout

Question 1

what are the treatment guidelines for an acute gouty attack?

Answer 1

monotherapy with:
1. NSAIDs
2. low dose colchicine
3. corticosteroids

if pain does not resolve:
- combo therapy (NSAIDS, low dose colchine)

if pain does not resolve:
- interleukin inhibitors (not often)

adjuncts: ice

Question 2

when to start pharmacotherapy for an acute gouty attack?

Answer 2

• initiate therapy within 24 hours
• ongoing urate lowering therapy should not be interrupted during acute treatment

Question 3

when is combination therapy for an acute gouty attack used?

Answer 3

if failed monotherapy

Question 4

what are acceptable combination therapy for an acute gouty attack?

Answer 4

1. Colchicine and NSAID
2. Oral corticosteroids and colchicine
3. Intraarticular steroids with all other modalities

Question 5

we should not used NSAIDs and systemic corticosteroids in combination. why?

Answer 5

similar MOA, will not increase the effect

increasing side effects

Question 6

which NSAIDs to use for an acute gouty attack?

Answer 6

all are considered effective when given at an anti-inflammatory dose
- stop after 2-3 days after clinical signs ends

Question 7

what is the most used NSAID for an acute gouty attack?

Answer 7

indomethacin
- lots of SEs: CNS, GI bleed

Question 8

when is colchicine recommended?

Answer 8

within 36 hours of gouty attack onset

Question 9

when to adjust the dose for colchicine?

Answer 9

• renal insufficiency
• hepatic insufficiency
• use with caution or strong CYP 34A inhibitors

Question 10

what are adverse effects of colchicine?

Answer 10

• GI effects (N/V/D, abdominal pain)
• Bone marrow suppression
• Myotoxicity (including rhabdomyolysis)

Question 11

when is colchicine CI?

Answer 11

• CrCl < 10ml/min
• Neutropenia
• Treatment of gout flare with colchicine is not recommended in patients receiving prophylactic colchicine and CYP3A4 inhibitors

Question 12

what is the dose of corticosteroids for gout?

Answer 12

Oral: prednisone 0.5mg/kg/day for 5 days
- might not need to taper

Question 13

when are corticosteroids used for gout?

Answer 13

Typically reserved for patients who do not tolerate or have CI to colchicine or NSAIDs

Question 14

what are long term adverse effects of corticosteroids?

Answer 14

• HPA suppression
• OP
• Cataracts
• Muscle deconditioning

Question 15

why are interleukin 1 inhibitors used for gout?

Answer 15

reduces infalmmation associated with gout
- off-label use

Question 16

What are the different interleukin 1 inhibitors

Answer 16

1. Anakinra
2. Canakinumab
   *used if combo therapy doesnt work

Question 17

when is long-term urate lowering therapy used for gout?

Answer 17

Any patient with established diagnosis of gouty arthritis AND one or more of the following:
- Tophus or tophi by clinical exam or imaging study
- Frequent attacks of acute gouty arthritis (≥2 attacks/yr)
- CKD stage 2 or worse
- Past urolithiasis

Question 18

what are the treatment guidelines for urate lowering therapy?

Answer 18

1. allopurinol
   - if allopurinol in CI –> febuxostat (both XOI)
2. febuxostat
3. probenecid with XOI
4. pegloticase if 1, 2, and 3 do not work

Question 19

what is the dose of allopurinol?

Answer 19

Starting dosage should be no greater than 100 mg/day for any patient
- Start at 50 mg/day with CrCl <60ml/min
- with renal impairment: monitor for toxicity

Question 20

what are the SEs of allopurinol?

Answer 20

• Nausea
• Diarrhea
• Rash (rare, can lead to Stevens-Johnson syndrome)
• Bone marrow suppression
• Allopurinol hypersensitivity syndrome (AHS)

Question 21

what drug can be used if there is a hypersensitivity to allopurinol?

Answer 21

febuxostat

Question 22

What are the Xanthine oxide inhibitors

Answer 22

1. Allopurinol
2. Febuostat

Question 23

What are the uricosuric therapy meds

Answer 23

1. Probenecid
2. Lesinurad

Question 24

When is Pegloticase used

Answer 24

1. In patient with severe gout disease burden and refractory to or an intolerance to oral ULT options

Question 25

what is the disadvantage of pegloticase?

Answer 25

expensive! $32,000 per dose

Question 26

What are the ADRs of Pegloticase

Answer 26

1. Infusion reactions

Question 27

when is prophylactic anti-inflammatory therapy recommended?

Answer 27

for all case scenarios of gout when ULT is initiated - crystals shift inside joints and might cause pain

Question 28

what are the drugs recommended for prophylactic anti-inflammatory therapy?

Answer 28

- Colchicine 0.6mg BID - Low-dose NSAIDs (e.g. naproxen 250mg BID) - Low-dose prednisone or prednisolone (<10mg daily)

Question 29

what is long-term management for gout?

Answer 29

- gout prophylaxis - monitor serum urate and ULT - urate levels under 6 mg - look for causes: meds, obesity, cancer, alcohol

Question 30

how to treat kidney stones that develop as a result of gout?

Answer 30

1. hydration (2 to 3L) 2. alkalize urine: potassium citrate or potassium bicarbonate 3. acetazolamide (250)