Medical Management PDF

11/27/23, 4:58 AM Realizeit for Student Medical Management Acute attacks are managed with colchicine (oral or parenteral), an NSAID such as indomethacin, or a corticosteroid. Management of hyperuricemia, tophi, joint destruction, and renal disorders is usually initiated after the acute inflammator...

11/27/23, 4:58 AM Realizeit for Student Medical Management Acute attacks are managed with colchicine (oral or parenteral), an NSAID such as indomethacin, or a corticosteroid. Management of hyperuricemia, tophi, joint destruction, and renal disorders is usually initiated after the acute inflammatory process has subsided. Once the acute attack has subsided, uric acid lowering therapy should be considered. Xanthine oxidase inhibitors, such as allopurinol and febuxostat, are the agents of choice. Given the role of IL-1 in the pathogenesis of gout, some experts suggest that there may be a role for anakinra, an IL-1 receptor antagonist in the management of acute gout (Becker & Perez-Ruiz, 2019). Management between gout attacks needs to include lifestyle changes such as avoiding purinerich foods, weight loss, decreasing alcohol consumption, and avoiding certain medications. Uricosuric agents, such as probenecid, may be indicated in patients with frequent acute attacks. Uricosuric medications correct hyperuricemia and dissolve deposited urate. Corticosteroids may also be used in patients who have no response to other therapy. In patients with refractory chronic gout who are not controlled with the regimens mentioned earlier, pegloticase, a newer agent, has been shown to be effective in lowering uric acid levels (Becker & Perez-Ruiz, 2019). Specific treatment is based on the serum uric acid level, 24-hour urinary uric acid excretion, and renal function (see Table 34-4). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/6 11/27/23, 4:58 AM Realizeit for Student Gout The treatment of gout involves the administration of NSAIDs and corticosteroids to reduce inflammation as well as uricosuric agents to increase the elimination of uric acid. Antigout Medication Mitotic Agent: Colchicine Colchicine (Colcrys), the prototype agent for the treatment and prevention of gout, is the most commonly administered antigout medication. Pharmacokinetics Colchicine is absorbed rapidly in the GI tract, with a slow onset of action; it reaches its peak in 1 to 2 hour. The drug is metabolized in the liver and has a half-life of 26 to 31 hours. It is primarily eliminated in the feces, with a smaller amount excreted in the urine. Colchicine crosses the placenta and enters breast milk. Action Colchicine inhibits the migration of WBCs into the body tissues containing urate crystals. The phagocytic action of the drug decreases the inflammatory reaction to the urate crystals deposited in the tissues. Use Colchicine is administered for the treatment and prophylaxis of acute gout in adults. Use in Older Adults Colchicine is administered cautiously in older adults, and the dosage should be reduced by half in people 70 years of age and older. Use in Patients With Renal Impairment For mild to moderate renal impairment, a regular dosage of colchicine is administered. If the creatinine clearance is less than 30 mL/min, a dosage adjusted is not necessary, but the drug should not be given more often than once every 2 weeks. For patients on dialysis, 0.6 mg is given as a single dose no more than once every 2 weeks. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/6 11/27/23, 4:58 AM Realizeit for Student Use in Patients With Hepatic Impairment In mild to moderate hepatic impairment, colchicine should be administered cautiously. The patient should be assessed closely for adverse effects. In severe hepatic impairment, the dosage should be the same, but the drug should not be given more often than once every 2 weeks. Adverse Effects GI adverse effects are the most common due to the absorption and elimination in the GI tract. These GI conditions include nausea, vomiting, and abdominal pain and dyspepsia. Hematologic adverse effects such as bone marrow depression and aplastic anemia may occur. Hepatotoxicity is also an adverse effect of colchicine. Other adverse effects include peripheral neuropathy, alopecia, rash, purpura, dermatoses, myopathy, muscle pain, and weakness. Contraindications Colchicine is contraindicated in patients who have a known hypersensitivity to the medication. It should not be administered concurrently with cyclosporines or ranolazine or with a strong to moderate CYP3A4 inhibitor in the presence of hepatic or renal impairment. It is administered cautiously in pregnancy or in the presence of renal or hepatic impairment. Nursing Implications Preventing Interactions Several medications, when combined with colchicine, result in toxicity and severe adverse effects. These agents increase the serum level of colchicine and the risk of toxicity. They are atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, diltiazem, erythromycin, fluconazole, and verapamil. In addition, colchicine should not be combined with grapefruit juice or alcohol. It also decreases cyanocobalamin (vitamin B12) absorption. Administering the Medication It is necessary to administer colchicine with food to reduce gastric distress. Assess for Therapeutic Effects Therapeutic effects occur within 24 to 48 hours after oral administration. The nurse assesses for decreased pain, swelling, and inflammation of affected joints. Edema may not decrease for several days. Assess for Adverse Effects https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/6 11/27/23, 4:58 AM Realizeit for Student The nurse assesses for severe GI adverse effects such as vomiting and diarrhea, which may lead to an alteration in fluid and electrolytes with dehydration. The nurse also assesses for numbness, tingling, or muscle weakness. In addition, it is important to assess for bone marrow depression. The nurse also monitors liver enzymes. Uricosuric Agents Several uricosuric agents are used to reduce serum uric acid levels. Allopurinol (Zyloprim), a xanthine oxidase inhibitor, is the prototype uricosuric drug. Pharmacokinetics Allopurinol is absorbed in the GI tract, with an onset of action of 24 to 48 hours and a peak of action of 2 to 6 hours. The drug's half-life is 1 to 3 hours. It is metabolized as an active metabolite oxypurinol and is eliminated slowly in the urine. It is also excreted in the breast milk. Action Allopurinol inhibits the enzyme that is responsible for the conversion of purines to uric acid. This action reduces the purines to uric acid and thus reduces the uric acid production to decrease the serum and urinary uric acid levels. The result of this action is the reduction of the symptoms of gout. Use Allopurinol and uricosuric agents are administered for the management of the signs and symptoms of primary and secondary gout or stages of gout. It is also given in acute and chronic tophaceous gout to reduce uric acid concentrations. Other indications include leukemia, lymphoma, and malignancies that result in elevated serum uric acid levels. Use in Older Adults Allopurinol may be used in geriatric patients. The initial dose is 100 mg/d, which can be increased until the desired uric acid level is obtained. It is necessary to maintain fluid intake to produce a urine output of at least 2000 mL/d. The dosage should be reduced in the event of diminished renal function. Use in Patients With Renal Impairment The dosage of allopurinol is reduced based on the patient's creatinine clearance. Use in Patients With Hepatic Impairment Allopurinol is administered cautiously in patients with hepatic impairment. The dosage does not need to be adjusted, but it is important to monitor liver function. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/6 11/27/23, 4:58 AM Realizeit for Student Adverse Effects Allopurinol has several adverse effects. CNS adverse effects include drowsiness, headache, and vertigo. Hematologic adverse effects are agranulocytosis, aplastic anemia, and bone marrow depression. The most common GI effects are nausea, vomiting, diarrhea, abdominal pain, and indigestion. Hepatotoxicity and renal insufficiency are risk factors with the use of allopurinol. Contraindications Patients with a known hypersensitivity to allopurinol should not take allopurinol. Also, patients with a family history or history of idiopathic hemochromatosis should not receive the drug. Nursing Implications Preventing Interactions Several medications, including azathioprine, mercaptopurine, cyclophosphamide, cyclosporine, and thiazide diuretics, increase the risk of uricosuric-associated toxicity. The administration of ampicillin and amoxicillin with allopurinol increases the risk of developing a rash. Anticoagulation effects are increased when combined with warfarin and aspirin. Alcohol combined with allopurinol decreases the excretion of uric acid. Administering the Medication It is necessary to administer allopurinol after meals to ensure absorption. Assess for Therapeutic Effects The nurse assesses for decreased pain, inflammation, and joint swelling. In patients with tophi, it is important to assess for increased joint mobility and decrease in tophi prominence. It is vital to assess serum uric acid levels. The normal serum uric acid level is 3.0 to 7.0 mg/dL. Assess for Adverse Effects The nurse assesses for diminished urine output or cloudy urine, which may be indicative of the development of uric acid kidney stones. It is also important to assess for GI effects such as nausea, vomiting, diarrhea, and abdominal pain. The nurse assesses for bruising, bleeding, and anemia. Finally, the nurse assesses aspartate aminotransferase and alanine aminotransferase levels for hepatotoxicity and creatinine clearance for renal insufficiency. Probenecid increases the urinary excretion of uric acid. This uricosuric action means that it can be used therapeutically to treat hyperuricemia and gout. It is not effective in acute attacks of gouty arthritis but prevents hyperuricemia and tophi associated with chronic gout. Probenecid may cause acute gout until serum uric acid levels are within the normal range; concomitant administration of colchicine prevents this effect. (Probenecid also is used with penicillin, most https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/6 11/27/23, 4:58 AM Realizeit for Student often in treating sexually transmitted diseases. It increases blood levels and prolongs the action of penicillin by decreasing the rate of urinary excretion.) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 6/6