PHARM - Gout Tx
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What non-pharmaceutical recommendations are NOT appropriate for someone with Gout?

  • Avoid medications that can cause hyperuricemia such as Thiazide, Loop diuretics, Niacin and High dose Aspirin
  • Limit water intake to help with decreasing the build up of uric acid (correct)
  • For acute flares, use ice, immobilization to decrease pain and swelling
  • Limit animal purines, organ meat, alcohol (beer), fructose

    • A patient presents with s/s of an acute flare of gout. What medications are first line therapist and are used as monotherapy?

  • Colchicine
  • Corticosteroids
  • NSAIDs
  • Any of the above are appropriate and first line (correct)

    • 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....

    <p>24 hours</p> Signup and view all the answers

    What patient description is not an appropriate candidate for NSAIDS?

    <p>All of the above</p> Signup and view all the answers

    What anti-inflammatory drug can be used for acute flares of gout, but can cause diarrhea and other GI symptoms?

    <p>Colchicine</p> Signup and view all the answers

    When is Colchicine not an appropriate choice for gout flares for patients?

    <p>CrCl &lt; 30 mL/min</p> Signup and view all the answers

    If a patient is taking a CYP 3A4 inhibitors (e.g., verapamil, ritonavir, cyclosporine, ranolazine), what medication must be dose reduced?

    <p>Colchicine</p> Signup and view all the answers

    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?

    <p>Corticosteroids</p> Signup and view all the answers

    What is not a side effect of corticosteroids?

    <p>acute kidney injury</p> Signup and view all the answers

    When are pharmacologic urate-lowering therapy (ULT) strongly recommended for patients with gout?

    <p>≥ 1 Tophi, Evidence radiographic damage, Frequent gout flares (≥2/year)</p> Signup and view all the answers

    When should a provider consider starting ULT in the patients?

    <p>All of the above</p> Signup and view all the answers

    When is ULT (Gout prophylaxis) recommend against?

    <p>A and B</p> Signup and view all the answers

    What is the preferred ULT (gout prophylaxis) for all patients profiles (including renal)?

    <p>Allopurinol</p> Signup and view all the answers

    Urate lowering therapy (ULT) options (Gout Prophylaxis)

    <p>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</p> Signup and view all the answers

    Uricosurics have increase risk of UA nephrolithiasis

    <p>True</p> Signup and view all the answers

    Allopurinol requires LOW starting dose to mitigate hypersensitivity syndrome.

    <p>True</p> Signup and view all the answers

    What medication can cause a sudden shift in UA mobilization which will exacerbate flare of gout?

    <p>Allopurinol</p> Signup and view all the answers

    What is the MAX dose for Allopurinol?

    <p>max 800 mg/day</p> Signup and view all the answers

    What is the initial dose of Allopurinol for a patient with normal kidney function?

    <p>100 mg daily</p> Signup and view all the answers

    What is the renal adjusted dose of Allopurinol for CrCl < 30?

    <p>50 mg daily</p> Signup and view all the answers

    If your patient cannot tolerate Allopurinol, what is the second-line option?

    <p>Febuxostat</p> Signup and view all the answers

    For patients taking Febuxostat, what needs to be monitored?

    <p>liver function tests</p> Signup and view all the answers

    What drug has a black box warning for cardiovascular events and should not be used in patients with a hx of cardiovascular events?

    <p>Febuxostat</p> Signup and view all the answers

    What medication can be added to XOI (Allopurinol) therapy at max dose when the patient is not attaining target UA level?

    <p>Probenecid</p> Signup and view all the answers

    What medication has a risk acute renal failure when used as monotherapy and is therefore ONLY approved for co-administration with XOI (allopurinolol)?

    <p>Lesinurad</p> Signup and view all the answers

    Continue ULT prophylaxis at least _____ months

    <p>3-6</p> Signup and view all the answers

    Ongoing evaluation and continued prophylaxis can be used as needed for continued flares and presence of tophi

    <p>True</p> Signup and view all the answers

    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.

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    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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