Gout Flashcards

Question

When is Colchicine used for the treatment of gout?

Answer 1

Used second line when NSAIDs are contraindicated or ineffective. E.g. CVD, Renal disease, GI toxicity Colchicine has a slower onset and high levels of toxicity Colchicine inhibits neutrophil migration into the joint. Colchicine should be administered ASAP, becomes less effective as time goes on.

Answer 2

0.5mg 2-4 times a day until relief of joint pain or development of GI side effects or total 6mg is taken. DO NOT repeat course within 3 days Lower dose of 0.5mg every 8hrs in elderly and patients with renal impairment. There is response to goat after 6 hrs, pain relief after 12 hrs and resolution after 48-72 hrs. Interactions ++ Side effects: - Nausea and vomiting - Abdominal pain - DIARRHOEA (stop therapy immediately) - Rashes, peripheral neuropathy, blood dyscrasias

Answer 3

Oral prednisolone can be given. Prednisalone 30-35mg daily Articular: e.g. Triamcinolone - Consider for mono arthritis for easy accessible joint

Answer 4

NSAID with colchicine or corticosteroid - Given for resistant gout

Answer 5

By the use of Urate Lowering Therapy - ULT. - Use of prophylaxis treatment helps avoid further complications such as tophi development or renal failure etc. - Prophylaxis treatment is important to prevent long term complication - Evidence for when they should be started is quite controversial because initial attacks of gout are often infrequent and self-limiting so at that point exposing the patient to unnecessary medication is not important. - CONSIDER ULT when patient suffers from two or more acute attacks per year. - They should also CONSIDER ULT if they have any signs of tophi, chronic gouty arthritis, joint damage, renal impairment, urolithiasis (formation of kidney stones), diuretic use and young onset gout attacks. Traditionally we DO NOT start prophylaxis therapy with ULT during an acute attack because: 1. Those patients would've had hyperuricaemia for couple years so theres no need to actually treat hyperuricaemia immediately if they are undergoing an acute attacks. 2. Agents used for prophylaxis actually work by reducing uric acid levels. There is evidence to show that changes in uric acid levels (increase or decrease) causes mobilisation of uric acid stores and as a consequence you prolong the attack or precipitate another.

Answer 6

- Reduces frequency of flares and acute attacks - Once crystals are dissolved by the ULT, it tends to avoid recurrence - Reduces size and number of tophi - Facilitates tophi disappearance - Improved quality of life

Answer 7

ALL ULT should be started at a LOW dose and titrated upwards - Monitor patient symptoms and titrate to serum uric acid (sUA) target. - Recommended during the first 6-months of ULT or during a dose titration - Colchicine - FIRST LINE 0.5 - 1mg daily (low dose) Reduce dose in renal impaired patients Where Colchicine is contraindicated or not tolerated: - Low dose NSAID or COXIB should be considered (consider cautions etc.) + Gastroprotection (e.g lansoprazole or PPI)

Answer 8

- First line choice drug for ULT - Controls symptoms - Some improvement in tophi (usually after about 6 months of treatment) - IT IS A XANTHINE OXIDASE INHIBITOR (Xanthine oxidase controls the last 2 steps of purine production to make uric acid) - It is a pro-drug, it undergoes hepatic metabolism to activate metabolite, OXIPURINOL - Start Allopurinol 1-2 weeks after acute attack subsided - If patient already on Allopurinol at onset of acute attack, then continue on it and treat acute attack at the same time. - Allopurinol can be used for prevention of diuretic induced hyperuricaemia (drug induced gout) if no alternative

Answer 9

- Starting dose for Allopurinol is 100mg daily - Increase dose every 3-4 weeks according to response to treatment to achieve LOW serum urate levels (Target sUA <300umol/L) - Usual maintenance 300mg daily (100-600mg) - Accumulate in renal impairment (Lower Dose 50-100mg daily)

Answer 10

- Rahes - Hypersensitivity reactions - GI disturbances

Answer 11

- Febuxostat is an alternative (another first line) to allopurinol if intolerant or contraindicated. - IT IS ALSO A XANTHINE OXIDASE INHIBITOR Dose: 80mg OD (can be increased to 120mg if uric acid levels >357umol/l after 2-4 weeks) - If patient is already on Febuxostat and suffer an acute attack, you would keep them on it whilst treating that acute attack. Side effects: - GI disturbances - Headache - Increased LFTs - Oedema - Rash - Rare but serious hypersensitivity reactions

Answer 12

Second line treatment in ULT alternative to Allopurinol/Febuxostat. Examples include: - Sulfinpyrazone - Probenecid (unlicensed) - Benzbromarone (unlicensed) Mechanism of action: - They are NOT xanthine oxidase inhibitors - They INCREASE uric acid EXCRETION by direct action on renal tubule. They should be AVOIDED if patient has any evidence of urate nephropathy as they can worsen the incidence of kidney stones or crystal formation. They are INEFFECTIVE in poor renal function (CrCl < 20-30 ml/min) Need to maintain high fluid intake when on these agents to reduce the risk of stone formation. Sometimes Uricosuric agents can be used in combination with xanthine oxidase inhibitor if we don't achieve an appropriate serum urate level with mono therapy.

Answer 13

- It is a subcutaneous injection - Made up on recombinant monoclonal antibody - Proved by NICE for Sever, refractory tophaceous gout Mechanism of action: Targets IL-1 associated with inflammatory response induced by urate crystals Contraindicated in current infection - due to risk of sepsis (life-threating reaction to an infection) VERY EXPENSIVE

Answer 14

Allopurinol + Azathioprine - Azathioprine metabolised to mercaptopurime - Mercaptopurine metabolised by Xanthine oxidase - Allopurinol causes accumulation -> Potentially fatal bone marrow suppression

Gout Flashcards

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