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98 Cards in this Set
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- Back
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symptoms of gout
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-hyperuricemia
-acute, recurring periods of arthritis -interstitial renal dz -uric acid nephrolithiasis |
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incidence of gout is correlated w/ ...
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age
serum Cr BUN male BP body weight alcohol intake |
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risk factors for gout
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-age
-SCr -BUN -male -BP -body weight -alcohol intake |
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hyperuricemia is defined as a serum UA of .....
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more than 7-7.5 mg/dl
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hyperuricemia is due to ...
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overproduction or underexcretion of UA
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t/f hyperuricemia is always symptomatic
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F
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causes of primary overproduction
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specific enzyme defects
see notes for exact enzymes |
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causes of secondary overproduction
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myelo-/lymphoproliferative disorders
infectious mononucleosis chronic hemolytic anemia |
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causes of primary underexcretion
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idiopathic
familial juvenile gouty nephropathy |
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secondary causes of underexcretion
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chronic renal mass/kidney injury
HTN sickle cell hypothyroid down's syndrome |
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high consumption of ... seems protective for hyperuricemia
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dairy products
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t/f hyperuricemia risk inc. w/ eating meat/beer/seafood
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T
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what foods are beneficial for ppl w/ gout
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high in complex carbs (fruits, veggies, whole grains)
low in protein (tofu) no more than 30% calories from fat (10% animal fat) - certain FAs from fish, flax, olive oil or nuts may have anti-inflamm benefits |
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drugs that can induce hyperuricemia and gout
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diuretics
salicylates cytotoxic drugs ethanol l-dopa pyrazinamide, ethambutol nicotinic acid, vit. B12 cyclosporine |
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in later phases of gout attack more _____ arrive and do what?
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macrophages
ingest urate crystals and release more inflamm mediators |
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if untreated an acute gouty attack will last...
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3-14 days
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signs and symptoms of an acute gout attack
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PAIN
erythema warmth swelling fever leukocytosis |
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where does acute gout occur and why
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peripheral joints of LE
low temp of joints and inc. intra-articular UA conc.-->at night water is reabsorbed leaving supersaturated sol'sn of urate which precipitates |
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how many joints are initially involved in an acute attack?
which is the most often affected? |
1
1st MPJ then instep, ankles, heels, knees, wrist, fingers and elbows |
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what can precipitate an acute attack
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stress
trauma alcohol infxn sx rapid lowering of UA by drugs |
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Dx of gout is best achieved ....
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from aspiration of synovial fluid-->ID MSU monohydrate crystals in leukocytes
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what renal complications are seen in gout
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nephrolithiasis
gouty nephropathy (acute and chronic) HTN nephrosclerosis |
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what % of gout pts get kidney stones
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10-25%
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t/f kidney stones in gout pts are made of UA
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F
can be UA, UA/Ca oxalate or pure Ca oxalate |
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UA stones are radiolucent/opaque?
Ca oxalate? |
UA- lucent
Ca- opaque |
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predisposing factors for nephrolithiasis
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-excess urinary excretion of UA
-acidic/highly conc. urine (pH of less than 6) -->spontaneous precipitation of stones |
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what is acute gouty nephropathy and how do you treat it
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when urine flow is blocked by massive precip. of UA crystals in collecting ducts or ureters (can occur after chemo)
allopurinol dec./prevents nephropathy |
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what causes chronic gouty nephropathy
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long-term deposition of urate crystals in renal parenchyma, microtophi may form
also see HTN and nephrosclerosis commonly |
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t/f hyperuricemia is in itself harmful to kidneys
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F,
prolly not |
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t/f chronic gouty nephropathy is reversible if gout is treated
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F
irreversible |
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t/f tophaceous gout is common among gout pts
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F
a late complicaiton uncommon in general pop. of gout pts |
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t/f tophaceous gout can cause carpal tunnel syndrome
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T
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what problems do tophi cause
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deformities
ST damage joint destruction pain nerve compression syndromes |
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most common sites for tophi
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base of great toe
helix of ear olecranon bursae achilles knees wrists hands |
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t/f long-term drug tx in an asymptomatic hyperuricemic pt can be helpful
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F
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t/f treat hyperuricemia when treating an acute attack
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F
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tx plan for acute gout
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initial NSAIDs
steroids if 1-2 joints colchicine used in onset of acute attack |
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where does colchicine come from
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autumn crocus
it's an alkaloid |
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t/f colchicine has no effect on UA
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t
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how long does it take for colchicine to relieve pain and inflamm
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12-24 hrs
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what is the traditional drug for treating pain and inflamm of acute gouty arthritis
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colchicine
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what are all the uses for colchicine
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acute gouty arthritis
prophylaxis of recurrent GArth. preventing acute mediterranean fever sarcoid arthritis |
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MOA of colchicine
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-anti-inflamm thru binding intracellular protein tubulin -->prevents polymerization into microtubules
-inhibit leukocyte migration, phagocytosis and LT B4 formation |
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ADRs of colchicine
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diarrhea*, NV,
acute intoxication (bloody diarrhea, shock, hematuria, oliguria, burning throat) fatal ascending CNS depression hair loss bone marrow depression |
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GI toxicity occurs in _____% of pts before relief of attack
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50-80
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what ADR of colchicine is specific to the elderly
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severe dehydration from diarrhea
serious electrolyte loss and death |
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t/f bioavailablity of colchicine is good
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F
25-50% |
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give colchicine early or late in attack?
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earlier is better*
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colchicine is dosed until...
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symptoms subside or NVD is intolerable
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what is the max dose of IV colchicine
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4 mg
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what do you need to do if you're giving colchicine IV
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dilute dose in 20 ml of normal saline to prevent sclerosis
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who should not get colchicine IV
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neutropenic pts
difficult to inject veins severe renal imparment (CrCL <10) combined renal/hepatic insufficiency |
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___% of acute arthr. pts respond to colchicine w/in ____ hrs of onset.
after ___ hrs. after onset, don't bother w/ colchicine |
75-90%
12 hrs 24 hrs |
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t/f clinical response to colchicine is pathognomonic for gout
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F
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no additional colchicine should be given for ___ days and oral colchicine should be d/c b/c of ...
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7 days
risk of bone marrow toxicity |
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MOA of NSAIDs in gout
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inhibit PG synth and urate crystal phagocytosis
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t/f you can use all NSAIDs to treat gout
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F
not ASA |
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which NSAID lowers serum UA levels
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oxaprozin
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when should you not use oxaprozin
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during active attack
can lead to crystal deposition |
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what pts should not take oxaprozin
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pts /w UA stones
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t/f newer NSAIDs are just as effective and safe as older drugs
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T
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what NSAID is most often used to treat acute gout
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indomethacin
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what drug is an alternative to colchicine for initial treatment of acute gout
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indomethacin
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how do you dose indomethacin?
why? |
large dose for first 24 hrs then taper therapy over 3-5 days
to dec. risk of recurrent attack and to dec. risk of kidney damage |
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don't give indomethacin to ...? why?
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elderly
b/c of PG inhibition in the kidney --> dec. kidney fxn* |
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name the uricosuric agents
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probenecid
sulfinpyrazone |
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uricosurics are good for what pts?
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evidence of tophi
several acute attacks high plasma UA levels (tissue damage is inevitable) |
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when after acute attack do you start uricosurics and why
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2-3 weeks after attack
can cause precipitation of UA calculi/tophi or another attack in pts who excrete lots of UA |
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w/ uricosurics it is important to maintain____ to dec. risk of ...
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large urine volume
stone formation |
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what drug may be used as an alternative to allopurinol
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uricosurics*
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t/f uricosurics are good for pts w/ dec. renal fxn
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F*
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MOA of uricosurics
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affect active transport so less of the filtered UA is reabsorbed and more is excreted
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ADRs of uricosurics
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GI (esp. sulf.)
rash (prob. more likely to cause allergic dermatitis) nephrotic syndrome from prob. aplastic anemia (both) |
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which is used more, sulfinpyrazone or probenecid
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prob b/c of sulf.'s ADRs
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what is special about fenofibrate
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lowers lipids and UA
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t/f uricosuric effect of fenofibrate is independent of lipid lowering effect
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T
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what does losartan do
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it's an ARB for HTN
also uricosuric also inc. urine pH which stops supersaturation and risk of stones/nephropathy is less |
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MOA of allopurinol
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dec. UA synth by inhibiting xanthine oxidase
pre-UA proteins are more soluble in urine |
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t/f allopurinol only works for overproducers
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F
works for both |
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t/f tx w/ allopurinol goes on for years or even lifelong
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t
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besides gout, allopurinol is used for
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antiprotozoal
prevent massive uricosuria following blood dyscrasias (chemo) |
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indications for allopurinol
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chronic tophaceous gout
pts w/ 24 hr. UA >600-700 mg intolerance/ineffective uricosurics recurrent renal stones pt w/ renal fxn impairment grossly elevated serum UA levels |
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t/f allopurinol is more effective in older pts
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F
younger |
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initial response to allopurinol is seen in ___ days, with peak in _____ days
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2-3
7-10 |
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ADRs of allopurinol
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NVD
allergic skin rxn acute attacks of GArth. peripheral neuritis bone marrow depression aplastic anmeia hepatic toxicity interstitial nephritis |
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what should be given for the first weeks of tx w/ allopurinol and why
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colchicine or an NSAID
to prevent GArth that can occur |
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what is febuxostat
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XO inhibitor for managing chronic hyperuricemia in gout pts
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ADRs of febuxostat
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upper resp. tract infxn
diarrhea muscle and CT symptoms |
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t/f febuxostat interacts w/ other gout meds
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F
no interxn w/ colchicine, naproxen or indomethacin |
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DDIs of febuxostat
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can block clearance of other xanthine-based drugs
azathioprine theophylline |
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what is rasburicase
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non-pegylated recombinant urate oxidase
used for tumor lysis syndrome |
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MOA of rasburicase
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oxidizes urate to allantoin (highly soluble in urine)
breaks down preexisting UA (allopurinol doesn't) |
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when do you start prophylaxis after first episode
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severe attack of GArth
UA lithiasis serum UA of >10 24 hr. urine UA of >1000 |
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how many attacks do you need to have before starting prophylaxis
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more than 2-3 per year
even if serum UA is normal |
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t/f never start prophylaxis if the serum UA is normal
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F
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how is colchicine used in prophylaxis
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low dose oral BID if no visible tophi
at beginning of attack increase dose to q 2 hrs |
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the goal of antihyperuricemic tx is to get serum UA below...
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6 mg/dl
well below saturation point |
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pt has recurrent acute GArth and significantly elevated. how do you manage it?
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uric acid lowering tx
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