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68 Cards in this Set
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- Back
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what are some of the characteristics of gout
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hyperuricemia
nephrolethiasis gouty arthritis gouty nephropathy monosodium urate crystal deposits |
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what is the end product of purine degredation
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gout
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what are the normal uric acid levels
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2-7 mg/dL
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what are the normal 24hr uric acid levels in urine
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women 600 mg/dL
men 800 mg/dL |
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what is the pathway for purine synthesis
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xanthine via xanthine oxidase gets converted to
uric acid uric acid via uricase gets converted to allantoin |
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what are the uric acid levels of a over producer
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>600 mg/dL on purine free diet
>1000 mg/dL on normal diet |
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what are the uric acid levels of underproducer
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<600 mg/dL
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how long is a purine free diet done
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3-5 days then followed by a 24 hr urine collection to check for uric acid levels
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what are some of the drug induced and disease related causes of gout
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drugs: diuretics esp TZD
disease: renal dysfunction (not getting rid of uric acid) |
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what are some of the diagnosis of gout
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monosodium urate crystals in fluid (definitive diagnosis, but requires tapping of joint)
tophi confirmed w/ crystal examination asymetric swelling w/in a joint or if the big toe is tender/swollen can also be indications but aren't definitive |
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gouty arthritis is acute or chronic
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acute
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what is the tx goal of acute presentations of gout
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tx pain and reduce inflammation/symptoms
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what are the tx goal of chronic presentations of gout
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prevent future attacks and damage
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what are some examples of chronic gout disorders
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hyperuricemia
uric acid nephorlethiasis tophaceous gout nephropathy |
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what are the characteristics of acute gouty arthritis
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often monoarticular
hot to touch and most common at night increases as you age >55 years |
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what are the expected labs in acute gouty arthritis
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increase leukocytes
fever left shift (increase neutrophils) |
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what are the characteristics of pseudogout
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it is the precipitation of calcium pyrophosphate dihydrate crystals (CPPD)
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what are the symptoms of pseudogout and how does it differe from gout
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fever and increase leukocytes (just as in gout)
KEY DIFFERENCE IS JOINT INVOLVEMENT gout = big toe pseudogout = knee |
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how can you differentiate b/t pseudogout and gout
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tap the join and check for what crystals are found
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what is tophaceous gout
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build up of tophi (urate crystals) that are left untreated this may progress to soft tissue damage and joint destruction
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patients with what type of gout require prophylaxis for life
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tophaceous gout
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what is 1st line for acute gout attacks
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NSAIDs
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what are the choices of NSAIDS to treat gout
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indomethacin
naproxen celecoxib ibuprofen |
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how are NSAIDs dosed
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large initial dose then taper down to prevent attack
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in treating gout what do NSAIDs do
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treat inflammation and pain
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what are the SE of NSAIDs
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hypertension (only give if pt BP under control)
fluid retention (don't give to CHF pt) CNS issues (indomethacin) GI bleed |
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how does Colchicine work
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prevents urate crystal deposition inot joints (DOESN'T DECREASE CURRENT URIC ACID LEVEL)
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what kind of Gout attacks can Colchicine be used to treat
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acute or chronic as prophylaxis
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what is the dosing of Colchicine for acute treatment
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1.2 mg NOW then 0.6 mg q1-2 hrs with max daily amount of 8 mg
if renal insuficiency (CrCL 30-80 mL/min) no need to adjust dose but if CrCL < 30 ml/min can only give once a week |
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what is the dosing for Colchicine for chronic treatment
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0.6 mg once or twice daily
renal dosing (CrCL <50 ml/min) 0.6 daily or every other day |
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when are steroids used to treat Gout
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when other drugs are contraindicated of refractory attacks (2nd/3rd attack)
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why aren't steroids 1st line
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due to immunosuppression, weight gain, insomnia
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what are some of the SE of colchicine
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N/V/D
myelosupression myopathy |
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what drugs should colchicine not be given with
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fibrates
statins these also cause myopathy |
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what are the steroid choices and how are they used
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Prednisone
Methylprednisone Triamcinolone |
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which steroid can be used for multiple joint involvement
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prednisone
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why don't you taper the dose of methylprednisone and triamcinolone
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they are one time doses
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what is uric acid nephrolithiasis
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formulation of uric acid stones (kidney stones)
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what are the TX for uric acid nephrolithiasis
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dietary changes
hydration: want UOP 2-3 L/day alkalize urine: Nabicarbonate/citric acid/sodium citrate acetazolamide 250mg allopurinol |
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what increase your risk of uric acid nephorlithiasis
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high urinary excretion of uric acid or acidic urine
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what are the criteria for gout prophylaxis
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Uric acid levels > 10 mg/dL
acute gouty arthritis in more than one joint reccurent acute attack (more than 2-3 a year) |
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when do you start gout prophylaxis
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after the acute phase of gout is over. meaning after you treat acutely with colchicine/nsaid/steroids you must wait 7-10 days before you start prophylaxis to prevent rebound
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what are some non Rx tx of gout
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decrease alcohol (wine is ok)
dietary modifications (turkey, steak, seafood are high in purines) |
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what drugs are used as prophylaxis for gout
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allopurinol
febuxostat |
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what is the MOA of allopurinol
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xanthane oxidase inhibitor
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what is the dosing for Allopurinol
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100mg daily then titrate up to 200-300 mg daily with 800 mg max daily
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what is the renal dosing for allopurinol
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if CrCl <60 ml/min give 200mg daily
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what drugs are contraindicated with both allopurinol and febuxostat
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mercaptopurine
azathiprine theophylline all of these require xanthane oxidase metabolism |
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what do you monitor w/ allopurinol
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CBC
LFT uric acid levels SCr |
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what is the MOA of febuxostat
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xanthane oxidase inhibitor
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when should Febuxostat be used with caution
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CrCl < 30 ml/min
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what must you monitor w/ Febuxostat
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CBC
uric acid LFT s/sx of MI/CVA ALT/AST |
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what are some SE of allopurinol
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rash (SJS)
nausea hepatotoxicity (Eventhough renally excreted) |
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what are SE of febuxostat
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CV events (increase risk of MI)
AST/ALT rise angioedema hypersensitivity rxn |
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what are the properties of Pegloticase
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recombinant form of uricase
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what kind of gout is pegloticase used to treat
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chronic gout refractory to other therapy
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what drug is part of the REMS program and what must you do b/c of this
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Pegloticase
have to premedicate with steroids and antihistamines |
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what gout drug must you use another agent with and why
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pegloticase
this is because pegloticase can increase risk of gouty attacks so to prevent these gout flares you must USE ANOTHER AGENT FOR 6 MONTHS AFTER INITIATING THERAPY WITH PEGLOTICASE |
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what are the uricosuric drugs
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probenecid
sulfinpyrazone |
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when are uricosuric drugs not used
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CrCl < 50 ml/min
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what is a major SE of Pegloticase
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gout flares
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how do uricosuric drugs work
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they increase renal clearance
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what kind of pt are uricosuric drugs best for
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underexcretors
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what gout drugs must be given w/ a lot of water
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allopurinol
uricosuric drugs (to prevent stone formation) |
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what do you monitor with uricosuric drugs
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uric acid
CBC SCr |
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why is pegloticase not often prescribed
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extremely expensive
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what is the ratio of spironolactone to furosemide
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100 spironolactone
40 furosemide |
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what is the weight loss goal when you're using spironolactone and furosemide
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0.5kg/day
1 kg/day edema |
