Gout

• NSAIDS
• Colchicine
  • unless used within past 14 days, hepatic dysfunction, Renal failure <30 or P450 inhibitor
    • 2mg now, 0.6mg 1 hour later
• Xanthine Oxidase inhibitors
  • Allopurinol
    • Test for HLA-B58:01 genotype in blacks/asians prior to starting
      • Associated with severe cutaneous adverse reactions (TEN/SJS)
      • Usually associated with CKD and diuretics, high mortality
      • 3% in Asians, 3.8% in Blacks, <1% in Whites
    • Start w/ 100mg/day
    • HLA-B58:01 associated with increased risk for allopurinol hypersensitivity syndrome, especially in Asians
    • Max allopurinol is 800mg/day
      • ½ dose if CKD 4/5
    • SE: MCMC of elevated Uric Acid
  • Febuxostat
    • 80mg-120mg/day
    • No renal adjustment/ increased risk of heart death

• Procine-derived Uricase

  • Severe recurrent +/- Tophaceous gout
  • Infused every 2 weeks, lowers urate to 0
  • 30-50% develop abs against drug in a month
  • Pegloticase
    • Used in severe recurrent and/or tophaceous gout intolerant or resistant to standard therapies
  • Rasburicase

• URAT1 transporter inhibitor

  • Uricosuric agents
  • Not as effective
  • CI: CKD, nephrolithiasis
  • Probenecid
  • Lesinurad