Gout & Hyperuricemia: Bagian Farmasi Klinik & Komunitas
Gout & Hyperuricemia: Bagian Farmasi Klinik & Komunitas
Gout & Hyperuricemia: Bagian Farmasi Klinik & Komunitas
Hyperuricemia
Ika Norcahyanti
Bagian Farmasi Klinik & Komunitas
Fakultas Farmasi UNEJ
Definisi
Gout
Drugs that decrease renal uric acid clearance include diuretics, nicotinic acid,
salicylates (<2 g/day), ethanol, pyrazinamide, levodopa, ethambutol, cyclosporine,
and cytotoxic drugs.
Uric acid nephrolithiasis occurs in 10% to 25% of patients with gout. Predisposing
factors include excessive urinary excretion of uric acid, acidic urine, and highly
concentrated urine.
Patofisiologi
In acute uric acid nephropathy, acute renal failure occurs because of
blockage of urine flow from massive precipitation of uric acid
crystals in collecting ducts and ureters.
Most common sites are the base of the fingers, olecranon bursae,
ulnar aspect of forearm, achilles tendon, knees, wrists, and hands.
Lokasi
Faktor Risiko
gender
age
drugs
kidney disease
Gambaran Klinis
Podagra Urate kidney stones
Tophi Nephropathy
Penegakan diagnosa
Definitive diagnosis requires aspiration of synovial fluid from the
affected joint and identification of intracellular crystals of MSU
monohydrate in synovial fluid leukocytes.
NSAID
Corticosteroid
GOUT attack
Colchicine
IL-1 inhibitor
Tata Laksana Terapi
NSAID…
NSAIDs have excellent efficacy and minimal toxicity with short term use.
Indomethacin, naproxen, and sulindac have Food and Drug Administration (FDA)
approval for gout, but others are likely to be effective .
Start therapy within 24 hours of attack onset and continue until complete resolution
(usually 5–8 days). Tapering may be considered after resolution, especially if
comorbidities such as hepatic or renal insufficiency make prolonged therapy
undesirable.
The most common adverse effects involve the GI tract (gastritis, bleeding,
perforation), kidneys (renal papillary necrosis, reduced creatinine clearance [CLcr]),
cardiovascular system (increased blood pressure, sodium and fluid retention), and
central nervous system (CNS) (impaired cognitive function, headache, dizziness)
Prednisone or prednisolone oral dosing strategies: (1) 0.5 mg/kg daily for 5 to 10
days followed by abrupt discontinuation; or (2) 0.5 mg/kg daily for 2 to 5 days
followed by tapering for 7 to 10 days. Tapering is often used to reduce the
hypothetical risk of a rebound attack upon steroid withdrawal.
Short term corticosteroid use is generally well tolerated. Use with caution in
patient with diabetes, GI problems, bleeding disorders, cardiovascular disease,
and psychiatric disorders. Avoid long term use because of risk for osteoporosis,
hypothalamic–pituitary–adrenal axis suppression, cataracts, and muscle
deconditioning.
Use only within 36 hours of attack onset because the likelihood of success
decreases substantially if treatment is delayed.
Xanthine oxidase
inhibitor
Hyperuricemia in
gout
Uricosuric drugs
Pegloticase
Tata Laksana Terapi
xanthine oxidase inhibitors
Patients with chronic kidney disease (stage 4 or worse) should start at a dose no
greater than 50 mg per day. Conservative dosing is intended to avoid allopurinol
hypersensitivity syndrome and prevent acute gout attacks common during
initiation of uratelowering therapy.
Initial probenecid dose is 250 mg twice daily for 1 to 2 weeks, then 500 mg twice daily
for 2 weeks. Increase the daily dose there after by 500mg increments every 1 to 2
weeks until satisfactory control is achieved or a maximum dose of 2 g/day is reached.
Because of its limitations, reserve pegloticase for patients with refractory gout who
are unable to take or have failed all other urate lowering therapies.
Evaluasi Terapi – Acute Gout
Monitor the patient for pain relief and decreased swelling of the affected
joint(s). Both parameters improve significantly within 48 hours of starting
therapy.
Assess the patient’s complaints and objective information
for adverse effects.
Monitor patients receiving intraarticular corticosteroid injections for
increased swelling or pain at the injection site.
Assess patients receiving systemic corticosteroids for mental
status changes, fluid retention, increased blood glucose, muscle weakness,
or development of new infections.
Evaluasi Terapi - ULT
Monitor the SUA level every 2 to 5 weeks during ULT
initiation and titration. Adjust the dose of ULT to achieve
a target SUA level of less than 6 mg/dL (357 μmol/L) or
optionally less than 5 mg/dL (297 μmol/L) in more severe
disease. Then continue measurements every 6 months thereafter.
Concomitantly initiate anti-inflammatory prophylaxis and
continue for the greater of 6 months or 3 to 6 months after
achieving target SUA level with no gout signs/symptoms.
Assess for new gouty arthritis attacks or development of
tophi.
Evaluate patients taking allopurinol for development of rash,
nausea, or new fever. These symptoms usually appear within
the first 3 months of therapy but can occur anytime.
Evaluasi Terapi - ULT
Evaluate patients prescribed febuxostat for presence of
nausea, arthralgias, rash, and transient elevation of hepatic
transaminase.
Assess patients receiving probenecid for fever, nausea, or
skin rash. Reevaluate therapy if a significant decrease in urine
output occurs.
If pegloticase is used, monitor SUA levels before each 2-week
IV infusion.
Evaluate patients on pegloticase for development of gouty
flares and infusion reactions, which may include anaphylaxis.
The manufacturer recommends giving an antihistamine and
perhaps low-dose methylprednisolone before the infusion to
minimize reactions.
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