36 Gout
A patient gave the pharmacist a prescription for Zyloprim 100 mg daily. Which of the following is an appropriate generic substitution for Zyloprim? A Allopurinol - Zyloprim B Probenecid C Pegloticase - Krystexxa D Colchicine - Colcrys E Febuxostat - Uloric
A
John is a 54 year-old male with hypertension and renal insufficiency. He presents to the clinic with severe pain and a very swollen big toe. John is diagnosed with gout, and given a prescription for prednisone. Which lab value is likely to be high in this patient? A Uric acid B Troponin C Platelets D Calcium chloride E Rheumatoid factor
A Correct Gout is caused by elevated uric acid in the joints. The uric acid crystallizes causing a very painful presentation. A painful, swollen big toe, or metatarsophalangeal joint, is a typical presentation for acute gout.
What is the rationale in using colchicine or an NSAID while beginning allopurinol therapy? A To reduce the risk of an acute flare B To reduce the risk of renal damage C To reduce the risk of mild or severe rash D To reduce the risk of crystallization in the urine E None of the above
A Correct NSAIDs or colchicine are used to reduce the risk of an acute flare while beginning uric-acid lowering therapy. It sounds counter-intuitive, but when beginning a potent agent such as allopurinol to lower uric acid, the patient may get an acute flare.
Which side effects occur in most patients from the use of colchicine? A Nausea, vomiting, diarrhea, abdominal pain B Headache, dizziness C Somnolence D Diplopia E Rash
A Correct Nausea, vomiting, diarrhea occur in ~80% of patients.
Which analgesic should not be recommended to help with the pain of an acute gout attack as it may increase uric acid levels? A Bufferin B Ibuprofen C Naproxen D Sulindac E Celecoxib
A Correct This contains aspirin.
Which of the following risk factors can increase a person's risk of gout? A Consuming beer B Being overweight C Having hypertension D Taking isoniazid for tuberculosis E Taking minocycline for chronic acne
ABC Correct Excessive alcohol consumption (especially beer), hypertension, and obesity are all risk factors for gout. Additional risk factors include male sex, chronic kidney disease, lead intoxication, advanced age, and medications that increase uric acid.
A patient is going to use a medication to reduce the incidence of future gout attacks. Which agent/s could be selected for gout prophylaxis? (Select ALL that apply.) A Allopurinol - Zyloprim B Probenecid - 2nd line agent C Prednisone D Febuxostat - Uloric E Naproxen
ABD Correct Allopurinol and febuxostat are considered first-line agents for gout prophylaxis. Probenecid is an alternative option for underexcreters. With ULT: Use colchicine 0.6 mg once or twice daily or NSAIDS for 3-6 months to reduce the risk of acute flares when beginning ULT
John is a 54 year-old male with hypertension and renal insufficiency. He presents to the clinic with severe pain and a very swollen big toe. John is diagnosed with gout, and given a ten-day prescription for prednisone. Which of the following are short-term side effects from the use of prednisone? (Select ALL that apply.) A Possible blood sugar elevation B Feeling "spacey" or irritable C Cushingoid side effects D Hypotension E Insomnia
ABE Correct He would not be at risk for adrenal suppression and consequent Cushingoid symptoms with a short course of therapy. Acute side effects -hyperglycemia -hypertension -nervousness -insomnia -increased appetite -edema
Which of the following are true regarding pegloticase? (Select ALL that apply.) A It should be reserved for refractory cases. B It is an inexpensive option for the chronic management of gout. C Anaphylactic reactions can occur during infusion. D It may be used in combination with allopurinol. E The brand name is Krystexxa.
ACE Correct Pegloticase in an expensive IV agent used for refractory gout. Anaphylactic reactions are common; therefore, patients should be premedicated with antihistamines and corticosteroids. Expensive - ~6500/dose DO NOT administer with Zyloprim - increased risk of ANAPHYLAXIS Risk of anaphylaxis highest when UA level is >6 mg/dL. Consider D/C treatment if UA is >6 mg/dL. DOES NOT block uric acid formation Converts uric acid to allantoin (an inactive and water soluble metabolite of uric acid)
Which of the following are risk factors for the development of gout? (Select ALL that apply.) A Hypertension B Renal insufficiency C Advanced age D Obesity E Excessive alcohol consumption
ALL Correct Risk factors include male sex, being overweight, excessive alcohol consumption (particularly beer), hypertension, renal insufficiency, advanced age and using medications that increase uric acid.
Which of the following medications can elevate uric acid? (Select ALL that apply.) A Niacin B Thiazide diuretics C Loop diuretics D Cyclosporine E Tacrolimus
ALL Correct Loop and thiazide diuretics, niacin, high-dose aspirin, pyrazinamide, cyclosporine, and tacrolimus are the medications with the highest know risk to increase uric acid. ASA, higher doses (no need to D/C low-dose ASA used for cardioprotection) Diuretics (thiazides, loops) Niacin Pyrazinamide Ribavirin Tacrolimus CSA
Which of the following dietary recommendations are thought to reduce the risk of future gout attacks? (Select ALL that apply.) A Consuming low fat dairy products. B Reducing intake of beef, lamb and pork. C Reducing intake of fresh fruits and vegetables. D Avoiding intake of organ meats, such as chopped liver. E Avoiding intake of high-fructose corn syrup.
ALL but C Correct To reduce the risk of recurrent gout attacks patients should avoid organ meats, high-fructose corn syrup and alcohol. Servings of fruit juices, table sugar, sweetened drinks and desserts, salt, beef, lamb, pork and seafood with high purine content (sardines, shellfish) should be limited. Low-fat dairy products, vegetables, hydration, weight loss and exercise are encouraged and may reduce the risk for gout attacks.
The use of probenecid can block renal clearance of some of the drugs that are cleared by the kidneys. Which of the following agents may have decreased clearance if taken in a patient using probenecid? (Select ALL that apply.) A Aspirin B Ampicillin C Methotrexate D Clopidogrel E Amoxicillin
ALL but D Incorrect Probenecid can block renal clearance of penicillins, methotrexate, theophylline and aspirin.
Uricosuric agents such as probenecid lower uric acid levels in the body by increasing the elimination of uric acid. These agents are not useful in many patients with gout since they require adequate: A Liver function B Renal function C Pulmonary function D Adherence E None of the above; probenecid is the drug of choice for most patients with gout who require a daily medication to lower uric acid.
B Correct Uricosuric agents such as probenecid lower uric acid levels in the body by increasing the elimination of uric acid. These agents are not useful in many patients with gout since they require adequate renal function.
A patient is having an acute gout attack. As an alternative to colchicine, which of the following treatment options can be recommended to help treat the acute pain and inflammation? (Select ALL that apply.) A Febuxostat B Naproxen C Allopurinol D Prednisone E Ibuprofen
BDE Correct Allopurinol and febuxostat are not used for acute gout treatment; it is used for prophylaxis (or prevention) of future gout attacks.
A patient with gout begins allopurinol 100 mg daily. The patient should be instructed to watch for this adverse effect, and to be seen promptly if it appears serious: A Bloody diarrhea B Weakness, malaise C Rash D Mental confusion and dizziness E Allopurinol is safe in all patients and has no risk of significant safety concerns
C Correct Although uncommon, this drug can cause rash which may be benign but can rarely develop into more serious reactions including toxic epidermal necrolysis or Steven-Johnson Syndrome. These can be fatal skin reactions. Can test for HLA-B*5801 - Koreans with stage III or worse CKD, Han Chinese or Thai irrespective of renal function Zyloprim
A patient has been given a prescription for colchicine 0.6 mg #12. Choose the correct dosing regimen for colchicine: A 1.8 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 2.4 mg - or 3 doses) B 1.8 mg orally followed by 0.6 mg in 1 hour x 2 (not exceed a total of 3.2 mg - or 4 doses) C 1.2 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 1.8 mg - or 3 doses) D 0.6 mg orally followed by 0.6 mg in 1 hour (not exceed a total of 1.2 mg - or 2 doses) E 1.8 mg orally X 1 dose
C Correct Colchicine (Colcrys) is taken at the first sign of an acute flare. Instructions are to take two of the 0.6 mg tablets. Another tablet can be taken in one hour. Three tablets, or 1.8 mg total dose, is the maximum per treatment. If the patient gets GI side effects after the initial dose they should not use the third tablet.
A pharmacist is going to counsel a patient beginning allopurinol therapy. Which counseling statement should be included? A This medication should be taken on an empty stomach. B Allopurinol can cause blood pressure changes; hold onto the bed or rail when changing from a sitting to a standing position. C If you notice a rash, contact your doctor at once. If the rash looks serious, you should not use the medicine and should be seen right away. D This medication should only be administered in a medical office. E The brand name of this medication is Colcrys.
C Correct Hypersensitivity reactions, including severe rash (SJ/S/TEN) can occur with allopurinol. A - Take after a meal to reduce stomach upset (higher doses can be divided). Drink plenty of fluids. E - Colcrys is colchicine. Allopurinol is Zyloprim. DO NOT administer with pegloticase (Krystexxa) - increased risk of anaphylaxis
What is the mechanism of action of allopurinol? A Uricosuric - probenecid B Inhibits sterol formation C Blocks crystallization by binding to calcium D Xanthine oxidase inhibitor E Binds to pyrimidines
D Correct Xanthine oxidase is the enzyme that catalyzes the reaction of xanthine to uric acid. It is blocked by the drugs allopurinol (Zyloprim) and febuxostat (Uloric).