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IPDM I WK 7 Hyperuricemia in Gout

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alchemist04's version from 2016-05-20 18:15

Section

Question Answer
Hyperuricemia treatment is to?prevent recurrence of gout attack by maintaining low Uric Acid (UA) levels (< 6 mg/dL or sometimes < 5 mg/dL
Is elevated UA an indication for prophylactic treatment?No, it is not
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Question Answer
Non-Pharm treatment of hyperuricemia?(1) Exercise, (2) weight loss, (3) reduce alcohol intake (4) Limit consumption of high-fructose corn syrup and purine-rich foods like Organ meats, Seafood
Pharm treatment of hyperuricemia, Urate-Lowering therapy 1st line? Xanthine Oxidase (XOI) like Allopurinol (Zyloprim) and Febuxostat (Uloric)
Pharm treatment of hyperuricemia, Urate-Lowering therapy - Alternate 1st lineProbenecid (Probalan)
Pharm treatment of hyperuricemia, Urate-Lowering therapy (1)(1) Uric acid Transporter 1 (URAT 1) inhibitors, could be adjunt with XOI but not with monotherapy e.g. Lesinurad (Zurampic)
Pharm treatment of hyperuricemia, Urate-Lowering therapy (2)(2) Urate-Oxidase Enzyme, for severe refactory gout e.g. Pegloticase
Pharm treatment of hyperuricemia, Urate-Lowering therapy (3)(3) Miscellaneous agents (off-label use) like Losartan (Cozaar), Fenofibrates (Tricor)
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Question Answer
Who shd be considered for prophylaxis gout treatment (1)(1) Pt having >/= 2 gouty attack per year
Who shd be considered for prophylaxis gout treatment (2)(2) Presence of one or more tophus
Who shd be considered for prophylaxis gout treatment (3)(3) CDK stage 2 or worse
Who shd be considered for prophylaxis gout treatment (4)(4) History or urolithasis (bladder stone)
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Question Answer
Allopurinol brand and dose?Zyloprim, 50-100 mg QD and only 50 mg in CKD stage 4
What is Allopurinol maximum dose?800 mg/Day
Warning for Allopurinol use (1)?(1) Hypersensitivity reaction/severe rash
Warning for Allopurinol use (2)?(2) Steven Johnson Syndrome (SJS)
Warning for Allopurinol use (3)?(3) recommended genetic testing for HLA-B*5801 prior starting therapy in Koreans w/ CKD stage >/= 4 and Han Chinese or Thai irrespective of renal Fx
Allopurinol side effects(1) Rash (2) increased LFTs (3) Acute gout attacks
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How shd we prevent Acute gout attack?Use daily Colchicine or NSAIDs for up to 6 mo concurrently to reduce the risk of acute attacks when starting Urate-lowering therapy
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Febuxostat brand and dose?Uloric, 40-80 mg daily
Febuxostat warnin?(1) Hepatotoxicity (2) Hypersensitivity (less than allopurinol) (3) Thromboembolic events
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Febuxostat contraindication? (1) concurrent use w/ azathioprine or mercaptopurine
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Uloric side effects?(1) Rash (less than allopurinol) (2) Increased LFTs (d/c if LFTs is > 3x ULN) (3) Acute gout attacks
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Lesinurad brand?Zurampic
Zurampic Counseling points (1)(1) Shd be used with XOI and not monotherapy
Zurampic Counseling points (2)(2) If XOI is interrupted, Lesinurad shd be stopped
Zurampic Counseling points (3)(3) Acute renal failure if used as monotherapy
Zurampic Counseling points (4)(4) Stay well hydrated (~2L/day)
Zurampic Counseling points (5)(5) 200 mg PO every morning (QAM) w/ a dose of XOI
Zurampic Counseling points (6)(6) Decreases efficacy of oral contraceptives (for females)
Zurampic Counseling points (7)(7) Contraindicated for CrCl < 30 ml/min, ESRD, Kidney transplant, dialysis
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Zurampic Adverse effects (1)(1) CVs problems
Zurampic Adverse effects (2)(2) Gout flares (recommend gout flare prophylaxis)
Zurampic Adverse effects (3)(3) Nephrotoxicity
Zurampic Adverse effects (4)(4) Headache
Zurampic Adverse effects (5)(5) Influenza
Zurampic Adverse effects (6)(6) GERD
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Question Answer
Lesinurad MOA (1)?(1) Uric Acid Transporter1 (URAT 1) inhibitor
Lesinurad MOA (2)?(2) URAT1 inhibit the Fx of transporter protein involved in uric acid reabsorption
Zurampic Metabolismsubstrate of CYP2C9, poor metabolizers of CYP2C9, have ~1.8 x higher drug exposure
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Uricosuric Agents MOA (1)(1) Increase renal excretion of UA by inhibiting proximal tubular reabsorption (2) Alternative 1st line
Uricosuric Agents examplesProbenecid (Probalan)
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Probenecid brand, dose?Probalan, 250 mg BID for 1wk
Pronececid, use?Useful in urate under-excretion
Probalan warning (1)(1) Increased risk of hemolytic anemia in patients with G6PD deficiency
Probalan warning (2)(2) Not recommended as monotherapy in patients with CrCl < 50 ml/min or history of urolithiasis
Probalan warning (3)(3) Avoid use in patients with CrCl < 30 ml/min
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Pronececid Contraindications (1)(1) Concomitant use of Aspirin (> 325 mg)
Pronececid Contraindications (2)(2) Urolithiasis
Pronececid Contraindications (3)(3) Initiation during acute gout attack
Pronececid Contraindications (4)(4) Blood dyscrasias
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Pronececid Contraindications (1)(1) Hypersensitivity reactions
Pronececid Contraindications (2)(2) Hemolytic Anemia
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Urate-Oxidase Enzyme MOAPegylated recombinant uricase
Pegloticase brand and use?Krystexxa, for severe refractory gout
Krystexxa dosing?8 mg IV infusion Q2wks (twice a week) over at least 2 hours
Krystexxa risk?risk of anaphylaxis (infusion related reactions), pre-mediated w/ antihistamine and corticosteroids
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Pegloticase precautions (1)(1) Discontinue or do not initiate any oral antihyperuricemic agents prior to initiating Pegloticase
Pegloticase precautions (2)(2) protect from the sun
Pegloticase precautions (3)(3) Refrigerate vials
Pegloticase precautions (4)(4) Do not shake
Pegloticase precautions (5)(5) must be used w/n 4 hrs after dilution
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Krystexxa contraindicationPatients with Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Krystexxa Warning (1)(1) Hypersensitivity/anaphylaxis
Krystexxa Warning (2)(2) May exacerbate Congestive Heart Failure (CHF)
Krystexxa Warning (3)(3) Immunogenicity
Krystexxa Warning (4)(4) Acute gout attacks
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Miscellaneous Agents Examples(1) Losartan (Cozaar) (2) Fenofibrate (Tricor)
Losartan brand and useCozaar, hypertension and Uricosuric effects
Fenofibrates brand and useTricor and Anti-hyperlipidemia
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Question Answer
True or false? Urate-lowering therapy in patients can cause an acute gouty attack?True
Long term effects of ULT (Urate lowering therapy) (1)(1) Uric Acid Nephrolithiasis
Long term effects of ULT (Urate lowering therapy) (2)(2) Gouty Nephropathy
Long term effects of ULT (Urate lowering therapy) (3)(3) Tophaceous Gout
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Acute Gout Prophylaxis + Patient compliance (1)(1) Concomitantly initiate acute prophylaxis w/ ULT
Acute Gout Prophylaxis + Patient compliance (2)(2) Start acute gout prophylaxis prior to initiating ULT
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Acute Gout Prophylaxis goal (1)(1) Improve patient compliance with ULT
Acute Gout Prophylaxis goal (2)(2) Prevent acute gouty arthritis attack
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Acute Gout Prophylaxis Pharm Therapy (1)(1) Colchicine (1st line of therapy), 0.6 mg daily or twice daily
Acute Gout Prophylaxis Pharm Therapy (2)(2) Low dose of NSAIDs (Naproxen 250 mg PO BID), may consider PPIs or H2-blockers if needed
Acute Gout Prophylaxis Pharm Therapy (3)(3) Low dose of Oral corticosteroids (use only if Colchicine is contraindicated/not tolerated/ineffective), Predinisone/Prednisolone <10 mg/day
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Question Answer
Acute Gout Prophylaxis Pharm Therapy duration (1)(1) At lest 6 months (Evidence A) OR
Acute Gout Prophylaxis Pharm Therapy duration (2)(2) 3 months after achieving the target serum urate level for the patient without tophi detected on physical examination (Evidence B) OR
Acute Gout Prophylaxis Pharm Therapy duration (3)(3) 6 months after achieving the target serum urate level, where there has been resolution of tophi previously detected on physical examination (Evidence C)
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