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Gout is a term for
collection of disorders that result from deposition of monosodium urate crystals in body tissue
Gout can be primary or secondary
Primary affects ____ 10 times more often
Secondary is associated with ______?
hyperuricemia- from diseases or drugs that interfere with secretion of uric acid, can be endocrine disorder, lead poisoning, or high doses of salicylates
90% of gout patients are _________ of uric acid?
under excretors of uric acid.
overproduction is less common and is usually from another disease
hyperuricemia is serum urate level in men?
men > 6mg/dl
women > 7 mg/dl
acute gouty arthritis definition
painful monoarthropathy of usually metatarsophalangeal joint of great toe.
Intercritical period (between attacks)
2nd episode usually within 6 months to 2 years after first attacks.
sodium urate crystals that are deposited in soft tissue occurs in 50% of patients.
key risk factors for gout
These factors are additive in terms of risk
- thiazide and loop diuretics
- alcoholism (moonshine is worse due to lead content) beer and spirits- not wine
- age > 60
- intake of meat and seafood increase the risk
most important diagnosis of gout is exclusion of _____ joint ?
-get synovial fluid for WBCs and diff, crystal analysis and gram stain with culture
Uricosuric (probenecid) agents MOA
increase secretion of uric acid
Tubular blocking agents, increase secretion by blocking reabsorption of urate
Increase risk of stones, increase fluids
- and NSAIDs- decreases or stops the inflammatory process.
- unknown but affects leukocyte fx to reduce lactic acid production.
Not an analgesic and has no effect on uric acid metabolism
NSAIDS and Colchicine MOA
decreases or stops the inflammatory process.
MOA of allopurinol
decrease the synthesis of uric acid
inhibit xanthine oxidase, the enzyme that converts xanthine to uric acid. Reduces uric acid production.
Does not promote uric acid secretion, so level in renal tubules in not increased
Prevention of gout reoccurrence use what meds?
Allopurinol, colchicine, and sulfinpyrazone
First line tx to reduce uric acid levels
what can be added if these meds are not working?
xanthine oxidase inhibitors- allopurinol or febuxostat
Urocosuric agents probenecid, fenofibrate, or losartan can be added if xanthine oxidase inhibitors are not sufficient to achieve target serum urate levels.
Gene testing for gout
Acute flairs may be treated with what
NSAIDS and glucocorticoids
prevention of attacks
first line is colchicine (decreases inflammatory response)
2nd line- Uricosuric (increase secretion) if undersecreter, allopurinol (decreases synthesis of uric acid) if over producer
Long term treatment for urate lowering drugs
How often to monitor serum uric acid levels?
baseline then every 2-3 months
Men serum uric acid level when monitoring drug response should be
women serum uric acid level when monitoring drug response should be
First time administration
first time- monitor weekly for toxicity (weakness, nausea, vomiting, diarrhea, and anorexia)
Periodic- LFTs and blood counts (every 3-6 months)
Can cause reversible malabsorption of B12
Monitoring Uricosuric agents
Allopurinol hypersensitivity syndrome
- Includes Steven Johnson Syndrome, usually present with rash.
- This is life threatening
- occurs rarely and is dose dependent.
Presents with fever, renal failure, and vasculitis, Mortality around 20%
Geriatrics and treatment
- diminished renal fx and risk of adverse effects increased.
- -begin with lowest dosage
- -monitor renal fx
Colchicine adverse reactions
- have caused death.
- Gastrointestinal toxicity in 80%
- -bone marrow suppression, blood dyscrasias, hepatic necrosis, and seizures most common in elderly.
safety not established for colchicine and sulfinpyrazone.
What drug is contradicted in children under 2 years old
- B- probenecid
- C- colchicine, allopurinol
- C/D- sulfinpyrazone
Patient education on all gout therapies
- educate on triggers, lifestyle, changes and use of various drugs
- -maintain adequate fluid intake
- -take meds with food to prevent GI upset
- -Report and S&S of GI distress
- -Lose weight slowly, to fast can cause gout attack
- -Stress compliance
Patient education on colchicine
notify of skin rash, sore throat, fever, unusual bleeding, bruising, tiredness, weakness, numbness, or tingling
Pt education and Uricosuric agents
- avoid aspirin or other salicylates can cancel drug
- -increase fluid to prevent stones
- -notify if rash develops
Allopurinol patient education
notify for what
Large doses of what may increase?
take meds with?
How long for optimal benefit?
- notify if rash, painful urination, blood in urine, irritation of eyes or swelling of lips and mouth.
- -large doses of vitamin C may increase kidney stones
- -take with fluid and food
- may take 6 weeks for optimal benifit
Death has occurred with as little as ___ mg of colchicine
Bone marrow suppression has occurred with long term tx of _______?
Allopurinol has been known to cause ___ toxicity
Acute gouty arthritis sx with out peptic ulcer, treat with?
Acute gouty arthritis sx with peptic ulcer tx with
Acute gouty arthritis sx with kidney liver or bone marrow disease tx with
recurrent and chronic gout- overproducer tx
allopurinol and colchicine
recurrent and chronic gout- undersecretor
Uricosuric agent- probenecid
hypersensitivity to allopurinol
includes Steven Johnson syndrome. Skin rash is earliest sign of reaction
colchicine is contradicted with what disease processes
heart disease, gi, renal and hepatic, and blood dyscrasias