Chapter 60 Gout
Treatment of gout
Asymptomatic hyperuricemia do not treat After attack use: -colchicine, NSAIDs, or steroids for pain/inflammation -prophylactic drugs to maintain level <6 XOI can cause acute gout flares so prepare with colchicine or NSAID febuxostat is only for those with allergy/intolerance or not effective with allopurinol if XOI does not work with level >6 -add on lesinurad or probenacid -replace XOI with IV pegloticasetrea
Lesinurad (Zurampic)
BBW: AKI esp. if used alone CI: CrCl <30, ESRD, dialysis, renal transplant ADRs: inc SCr, renal harm take with lots of water
Pegloticase (Krystexxa): IV Q2Wks
BW: anaphylaxis, premed with steroids and AHs, highest rx when UA >6 CI: G6PD deficiency: life threatening affect on RBCs W: gie colchicine 1 week prior and at least 6 mo after d/t flares upon initiation
Febuxostat (Uloric)
CI: do not use with didanosine, mercaptopurine, aza, or pegltoicase BBW: inc rx of CVD death, reserved for allopurinol intolerance or not effective W: hepatoxic, thromboembolic events, also serious skin rxn (TEN/SJS/DRESS) ADR: inc LFTs use ppx doses of colchicine and NSAIDs for 3-6mo
Colchicine (Colcrys) Info
CI: strong Pgp or 3A4 inhibitors w/ renal or hepatic dz W: GI (anorexia N/V/D); rhabdo/myopathy rx with certain drugs ADR: N/D, myelo, myopathy, neuropathy
Normal UA (depends on gender) mg/dL
F: 2-6.5 M: 3.5-7.2
Steroids
Intra-articular dose not cause systemic side effects intra-articular dose is used if limited to 1-2 joints
allopurinol
W: severe rash (SJS/TEN), test HLAB5801; hepatotoxic ADR: rash, nausea, acute flares high doses used for TLS used with ppx doses of colchicine or NSAID for 3-6 mo to prevent flares doses >300mg should be divided take with or after meal to reduce nausea
Acute attack
apply ice for pain and inflammation continue preventative drugs use just one acute drug (if severe can use colchicine + steroid or NSAID) localized severe use intra-articular steroid
Colchicine (Colcrys) dose
has treatment and ppx doses; both require adjustments if CrCl <30 ppx 0.6mg once of twice daily treatment two 0.6mg tabs (1.2mg) followed by one 0.6mg tab 1h later (NTE 1.8mg in 1h or 2.4mg/d) may repeat treatment dose no earlier than 3d needs to be taken w/in 36h of s/sx onset if using it as a ppx dose already, wait 12h before resuming ppx dose after a trx dose
Probenacid
only highlight: can inc beta-lactam levels
NSAIDs
only indomethacin, naproxen, and sulindac are approved for gout but others can also be used
Drugs and Foods that increase UA/gout
organ meats, HFCS, EtOH low doses of ASA diuretics Niacin Pyrazinamide Some pancreatic enzymes CNI Chemos (TLS)
Difference between the two uricosurics
probenacid can replace or be used with an XOI lesinurad has to be use with an XOI
Pegloticase anaphylaxis
serious and higher risk if using with XOI or probenacid; do not use either of these 3 with pegloticase