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gout pharmacy
| Question | Answer |
|---|---|
| what is gout? | uric acid crystalizes in the joint causing intense pain and inflammation. Pain mostly at night and abruptly |
| scenario of what a pt goes through with gout | pt goes to bed in good health and wakes up abruptly in the middle of the night at 2am with severe pain in his big toe. Fever and chills follow. The pain is so bad he cannot bear weight of his sheet on his big toe. |
| explain an initial gout attack | typically invovles one joint, 50% big toe (metatarsophalangeal joint) called a PODAGRA. |
| if gout is untreated? | spontaneously resolves in 2 weeks. pt suffered. pt may develop TOPHI, uric acid stones or nephropathy so we want to treat it |
| are there labs to draw? | serum uric acid levels (normal 2-7.2mg/dL). |
| hyperuricemia labs | UA> 7.2mg/dL males; 6 in females |
| Uric acid is an end product of... | purine metabolism |
| describe uric acid production | uric acid is an end product of de novo synthesis. tissue catabolism and purines in diet contribute. xanthine --> uric acid via xanthine oxidase |
| elimiate these foods because they are high in purine content | alcohol, beer, tea, coffee. grains, oatmeal, vegetables. peas, beans spinach lentils asparagus animal/fish based meat extract like gravy yeast cholocolate poultry seafood |
| what is pt has hyperuricemia but never had an attack. should i start therapy? | the onset of gout is preceded by a period of latency when the pt is asx and elevated UA levels. it may be years before pt develops gout and only a fraction of hyperuricemic pts develop gout. therefore do not put an asx pt without an attack hx on rx meds |
| drugs that can raise UA levels | asa>2g, cytotoxic drugs, diuretics (hctz/furosemide), ethanol, levodopa, nicotinic acid, theophylline, didanosine, ethambutol, laxative abuse, methoxyflurane, pyrazinamide |
| factors associated with hyperuricemia | obesity (wt loss helps UA levels), htn, excess alcohol, renal impairment, drugs |
| treatment goals | rest and apply cold packs, take therapy. prevent future attacks. reduce serum UA. lifestyle mod, prevent complications with chronic disease |
| DOC for acute attacks | nsaids or steroids. occasionally colchicine (gi se/watch for rare se if tolerated) |
| do you start colcichine before or after initial therapy? | you can use before and during start of allopurinol tx (to prevecnt future attacks). there is a risk of initial acute attack when beginning prophylactic tx and colchicine can be used to reduce this risk |
| Which NSAIDS to use? | any can be used. indomethacin, naproxen, sulindac FDA approved but caution indomethacin in elderly |
| which cant be used in elderly? | indomethacin cautioned b/c cns side effects and highly GI toxic. no nsaids used if renal insufficiency or heart failure or GI bleed hx/high risk dont use |
| steroids? | prednisone or prednisolone orally or injections can be used into joint to lessen systemic effects |
| what is gold standard for acute attack? | indomethacin (indocin) for no other reason but it was the first approved. 50mg tid to qid (max 200mg) x 2-3 days. all nsaids started high and tapered down |
| indomethacin | indocin |
| indocin | indomethacin |
| taper for acute attacks? | taper dose done until attack totally resolved. taper to avoid risk of rebound attack. |
| nsaid side effects | gi toxic, ha, depression, spaced out feeling |
| naproxen dose | alternative for indomethcin 500-1000mg intially, 250mg tid until attack resolved (TID DOSING FOR GOUT, otherwise BID) |
| sulindac | clinoril |
| clinoril | sulindac |
| sulindac dosing | eliminated inactive and used to be thought safer in renal insuff. 200mg bid (max 400mg/day) |
| why use colchicine | alternative if intolerant to NSAIDS or prevent flare ups in pts tapering steroids or starting uric acid lowering treatment. MOA poorly understood, inhibits neutrophil migration into synovial fluid, degranulation of lysozymes, inhibits leukotrienes. |
| colchicine unique moa (maybe) | may possess antimitotic effects interfering with inflammatory processess |
| colchicine dose | oral 2 0.6mg tablets inititally. one every hous until joint pain symptoms relieved for GI side effects develop (NVD) or a total of 6mg total (10 tablets) |
| colchicine iv | IV 1mg dose (max 4mg/d) if oral not available or GI side effects. incresed risk of cytotoxic or toxic effects like bone marrow suppression, renal hepatic cell damage |
| common colchicine effects | nvd abdominal pain. may happen before pain relief achieved in elderly. may lead to dehydration/electrolyte abnormal D/C drug if appears |
| long term se of colchicine | leukopenia, mypopathy, neuropathy, alopecia, azoospermia more likely if pt has renal insufficiency |
| corticosteroids | inhibits PG synthesis. oral prednisone 30-50mg/day over 3-5 days taper down by 5mg/day for 1-2 weeks. methyprednisolone na succinate iv for acute cases up to 150mg infused over 1/2 hour and taper down over several days. triamcinolone into joints or IM |
| steroid ae | gi upset po, hyperglycemia, increased appetite and rebound attacks, occur short term. long term osteoporosis, edema, pud dx |
| how to PREVENT future gout attacks | consider colchicine 0.6mg daily beginning 1-2 weeks preior to allopurinol start to prevent early attack |
| allopurinol moa | overproducer and under excretors. works on all! inhibits xanthine oxidase the enzyme responsible for synthesizing UA. the end products of pyrine metabolism are now hypoxanthine and xanthine |
| max dose allopurinol | 800 mg/day. if dosing 300mg> split bid. typical dose is 300mg daily. check crcl |
| renal dose allopurinol | crcl <60 max 200mg/day. if crcl<30 max 100mg/day |
| normal renal fx dose of allopurinol | 50-100mg/day increase weekly by 100mg until ua in desired range |
| ae common of allopurinol | precipitation of acute attacks, nausea, skin rash. serious rxn like toxic epidermal necrolysis or steven johnson syndrome d/c it pt presents with rash. if mild pt can't use other agents and allopurinol may be reintroduced cautiously. |
| name uricosurics | sulfinpyrazone and probenecid for younger pts only. requires good renal fx and not if on 150mg asa or diuretic tx |
| probenecid | benemid |
| benemid | probenecid |
| sulfinpyrazone | anturane |
| anturane | sulfinpyrazone- rarely used b/c antiplatelet effects |
| uricosurics used when | in pts considered underexcretors or uric acid and works on kidneys so can't use in pts with decreased renal fx |
| di with urosurics | asa and diuretics reduce effectiveness of both agents |
| probenecid dose | usually 500mg daily |
| se probenecid | gi disturbances, rash, kidney stone formation |
Created by:
pacific989