28 Questions
What non-pharmaceutical recommendations are NOT appropriate for someone with Gout?
Limit water intake to help with decreasing the build up of uric acid
A patient presents with s/s of an acute flare of gout. What medications are first line therapist and are used as monotherapy?
Any of the above are appropriate and first line
When it comes to acute flares of gout, there are better outcomes with early treatment (≤ 24 hours).
True
When are NSAIDS most effective in the reduction of pain and inflammation for acute gout? Within....
24 hours
What patient description is not an appropriate candidate for NSAIDS?
All of the above
What anti-inflammatory drug can be used for acute flares of gout, but can cause diarrhea and other GI symptoms?
Colchicine
When is Colchicine not an appropriate choice for gout flares for patients?
CrCl < 30 mL/min
If a patient is taking a CYP 3A4 inhibitors (e.g., verapamil, ritonavir, cyclosporine, ranolazine), what medication must be dose reduced?
Colchicine
A patient is experiencing an acute flare of gout. They are older than 65 years and has a CrCl <30 mL/min. What drug would you now pick?
Corticosteroids
What is not a side effect of corticosteroids?
acute kidney injury
When are pharmacologic urate-lowering therapy (ULT) strongly recommended for patients with gout?
≥ 1 Tophi, Evidence radiographic damage, Frequent gout flares (≥2/year)
When should a provider consider starting ULT in the patients?
All of the above
When is ULT (Gout prophylaxis) recommend against?
A and B
What is the preferred ULT (gout prophylaxis) for all patients profiles (including renal)?
Allopurinol
Urate lowering therapy (ULT) options (Gout Prophylaxis)
Inhibits enzyme responsible for conversion of xanthine to uric acid (↓ UA production) = Xanthine oxidase inhibitors (XOI) Drugs: Allopurinol (Zyloprim), Febuxostat (Uloric) = Xanthine oxidase inhibitors (XOI) Inhibits reabsorption of uric acid (↑ UA excretion) = Uricosurics Probenecid, Lesinurad = Uricosurics
Uricosurics have increase risk of UA nephrolithiasis
True
Allopurinol requires LOW starting dose to mitigate hypersensitivity syndrome.
True
What medication can cause a sudden shift in UA mobilization which will exacerbate flare of gout?
Allopurinol
What is the MAX dose for Allopurinol?
max 800 mg/day
What is the initial dose of Allopurinol for a patient with normal kidney function?
100 mg daily
What is the renal adjusted dose of Allopurinol for CrCl < 30?
50 mg daily
If your patient cannot tolerate Allopurinol, what is the second-line option?
Febuxostat
For patients taking Febuxostat, what needs to be monitored?
liver function tests
What drug has a black box warning for cardiovascular events and should not be used in patients with a hx of cardiovascular events?
Febuxostat
What medication can be added to XOI (Allopurinol) therapy at max dose when the patient is not attaining target UA level?
Probenecid
What medication has a risk acute renal failure when used as monotherapy and is therefore ONLY approved for co-administration with XOI (allopurinolol)?
Lesinurad
Continue ULT prophylaxis at least _____ months
3-6
Ongoing evaluation and continued prophylaxis can be used as needed for continued flares and presence of tophi
True
Study Notes
Non-Pharmaceutical Recommendations for Gout
- Non-weight-bearing exercises are not appropriate for someone with gout.
Acute Flares of Gout
- First-line therapy for acute flares of gout includes NSAIDs and corticosteroids, which are used as monotherapy.
- Early treatment (≤ 24 hours) is crucial for better outcomes.
- NSAIDs are most effective in reducing pain and inflammation within 24 hours of symptom onset.
Contraindications and Precautions
- NSAIDs are not suitable for patients with a history of GI bleeding, kidney disease, or heart failure.
- Colchicine is not an appropriate choice for gout flares in patients with kidney disease (CrCl < 30 mL/min).
- Patients taking CYP 3A4 inhibitors (e.g., verapamil, ritonavir, cyclosporine, ranolazine) require a dose reduction of colchicine.
Medication Options
- Corticosteroids can be used for acute flares of gout, but may cause diarrhea and other GI symptoms.
- Febuxostat is a second-line option for patients who cannot tolerate allopurinol.
Urate-Lowering Therapy (ULT)
- ULT is strongly recommended for patients with gout who have frequent flares (≥ 2 per year), tophi, or kidney disease.
- Providers should consider starting ULT in patients with a history of frequent flares or tophi.
- ULT is not recommended for patients with asymptomatic hyperuricemia.
- Xanthine oxidase inhibitors (XOIs) are the preferred ULT for all patient profiles, including renal.
- Uricosurics have an increased risk of UA nephrolithiasis.
- Allopurinol requires a low starting dose to mitigate hypersensitivity syndrome.
Allopurinol Dosing
- The maximum dose of allopurinol is 800 mg/day.
- The initial dose of allopurinol for patients with normal kidney function is 100 mg/day.
- The renal adjusted dose of allopurinol for CrCl < 30 mL/min is 50 mg/day.
Monitoring and Side Effects
- Febuxostat requires monitoring of liver function tests.
- Allopurinol can cause a sudden shift in UA mobilization, exacerbating flares of gout.
- Corticosteroids do not cause weight gain as a side effect.
- Febuxostat has a black box warning for cardiovascular events and should not be used in patients with a history of cardiovascular events.
Combination Therapy
- Lesinurad can be added to XOI therapy at max dose when the patient is not attaining target UA level.
- Lesinurad has a risk of acute renal failure when used as monotherapy and is therefore only approved for co-administration with XOI.
Prophylaxis
- Continue ULT prophylaxis at least 3 months.
- Ongoing evaluation and continued prophylaxis can be used as needed for continued flares and presence of tophi.
Test your knowledge on non-pharmaceutical recommendations that are NOT appropriate for individuals with Gout. Identify which lifestyle changes or remedies should be avoided to manage Gout effectively.
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