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Gout (Monitoring (NSAIDs (therapeutic (resolution of pain, avoidance of…

- - - - resolution of pain, avoidance of gout attacks when used for prophylaxis
    - - BP, kidney function, edema, dark stools
  - - - glucose levels in pt with DM
    - - resolution of pain, avoidance of gout attacks when used for PPX
  - - - resolution of pain
    - - signs of rebound arthritis (pain relief followed by reemergence of pain)
  - - - serum urate level, reduced frequency of gout attacks
    - - kidney function
  - - - serum urate levels, reduced frequency of gout attacks
    - - signs/sx of anaphylaxis following infusion
  - - - resolution of pain
  - - - serum urate level, reduced frequency of gout attacks
    - - liver function tests, kidney function
  - - - resolution of pain, avoidance of gout attacks when used for PPX
    - - GI sx, CBC
  - - - rash, kidney function
    - - serum urate level, reduced frequency of gout attacks
  - - - resolution of pain, avoidance of gout attacks when used for PPX
    - - neutrophil count (prior to initiation, monthly for the first 3 months of therapy then after 6, 9, and 12 months of therapy), temperature (periodically to detect infection)
  - - - serum urate level, reduced frequency of gout attacks
    - - kidney function
- - - - indomethacin is a favorite for acute gout flare
      - excellent efficacy and minimal toxicity with short term use
      - Adverse Effects
        
        GI, renal toxicity, CV, CNS
      - COX-2 selective
        
        may confer less risk than nonselective agents in regards to GI issues
        
        Consider CV risks
      - Celecoxib is recommended as option for those unable to tolerate traditional NSAIDs
    - - For acute gout flares when contraindications exist for other therapies
      - systemically or by intra-articular injection
        driven by # of joints affected
      - Oral systemic therapy (prednisone or prednisolone):
        0.5 mg/kg daily for 5-10 days then abrupt d/c
        0.5 mg/kg daily for 2-5 days followed by a taper of 7-10 days
        methylprednisolone dose pack (6 day regimen)
      - Intra-articular: triamcinolone acetonide in a dose of 20-40 mg
        use if 1 or 2 joints are involved
      - Mixed data on efficacy of monotherapy vs combined with NSAID, cochicine, oral corticosteroid therapy
      - dose & duration dependent SE
        short term use is well tolerated
        long term use: osteoporosis, hypothalamic-pituitary axis suppression, cataracts, and muscle deconditioning
      - Corticotropin & Adrenocorticotropic Hormone - stimulates the adrenal cortex to produce cortisol and corticosterone
        Given IM for 2-3 days
    - - antimitotic drug that is highly effective at relieving acute attacks of gout
      - should be initiated within 24hr of acute attack
      - 0.6mg oral daily is approved
      - Adverse effects
        
        nausea, vomiting, diarrhea
        neutropenia
        axonal neuromyopathy
    - - reduce uric acid by impairing the ability of xanthine oxidase to convert hypoxanthine to xanthine and xanthine to uric acid
      - Allopurinol
        
        AE: skin rash, leukopenia, GI problems, headache, and urticaria , SEVERE: allopurinol hypersensitivity reaction
        
        Risk Factors: women >60yrs, starting doses >100mg/day
        kidney disease, CV disease, HLA-B*5801 allele
        
        gradually titrated every 2-5 weeks up to a max dose of 800 mg/day until serum target is met
      - Febuxostat
        
        lowers serum urate concentrations in a dose-dependent manner
        
        does not require renal or hepatic dose adjustment
        
        increased mortality and CV mortality compared to allopurinol
        
        should be reserved for patients who have intolerance or fail to meet goals with allopurinol
    - - limited to pts with CrCl >45-50 ml/min
      - Lesinurad
        
        selective uric acid reabsorption inhibitor
        
        inhibits URAT1
        
        approved as combo therapy with xanthine oxidase inhibitors
        
        BBW for increased risk of AKI
        should not be used in CrCl <45 ml/min
      - probenecid
        
        initial dose 250mg BID for 1-2 wks, then 500mg BID for 2 wks
        
        AEs: GI irritation, rash and hypersensitivity, precipitation of acute gouty arthritis
        
        may interact with salicylates so use aspirin with caution
        
        can inhibit the tubular secretion of other organic acids, and increase concentrations of penicillins, cephalosporins
      - Pegloticase
        
        reduces serum uric acid by converting uric acid to allantoin
        
        biweekly IV infusion -- given over at least 2hr
        
        must be treated with antihistamines & corticosteroids
        
        LAST resort if failed all other ULTs
  - - - local ice application
      - complementary/alternative medicines NOT recommended
    - - indomethacin has been historically favored, but little evidence to suggest that any NSAID is better than another
      - indomethacin, naproxen, sulindac are only FDA approved NSAIDs for gout
      - therapy initiated within 24 hours is most likely to be effect
    - - can be systemic if intraarticular (usually use systemic only if multiple joints involved)
      - usually 0.5 mg/kg daily for 5-10 days with no taper
        or 0.5 mg/kg daily for 2-5 days followed by 7-10 day taper
        or medrol dose pack
      - typical corticosteroid precautions
        
        hyperglycemia
        
        GI problems
        
        Osteoporosis, HPA axis suppression, muscle deconditioning with long-term use
      - ACR guidelines also recommend corticotropin, which stimulates endogenous cortisol
    - - antimitotic
      - start within the next 24 hours
      - dosed 1.2 mg initially, followed by 0.6 mg one hour later
      - use caution with Pgp or 3A4 inhibitors