Gout
Answer a is correct. The antihypertensive hydrochlorothiazide can contribute to hyperuricemia, and if possible, it should be avoided in patients with gout. Answers b and c are incorrect. These antihypertensive agents are not associated with elevated SUA levels and are good choices for many patients with gout. Answer d is incorrect. This nonsteroidal anti-inflammatory drug (NSAID) is used to treat pain and inflammation associated with gout, and it does not cause elevated SUA levels.
60-year-old man presents to the pharmacy with a past medical history of hypertension and gout. After reviewing his medication profile, which medication is most likely to cause elevated serum uric acid (SUA) levels? A Hydrochlorothiazide B Losartan C Amlodipine D Indomethacin
nswer: C Option A: Incorrect. The presence or absence of the HLA-B*5801 allele is not an indication for initiating urate-lowering therapy in patients. Option B: Incorrect. At least one subcutaneous tophus is needed to begin urate-lowering therapy. Option C: Correct. At least two gout flares annually is an indication for initiating urate lowering therapy. Option D: Incorrect. There is no requirement of having at least two joints involved to begin urate-lowering therapy.
A 27-year-old man presents to urgent care with a swollen left foot, stating "my large toe is in severe pain." He tried taking naproxen for the pain and is now asking for "something stronger." He has no past medical history, denies use of tobacco, and endorses socially drinking whiskey with coworkers and friends. What would be an indication for initiating urate lowering therapy for him? A Negative for the HLA-B*5801 allele B At least three subcutaneous tophi C At least two gout flares annually D At least two joints involved
C
A 30-year-old man presents to clinic newly diagnosed with gout. His past medical history is significant for type 2 diabetes mellitus, hypertension, and asthma. He reports eating "whatever food he can get at gas stations" and drinks a six-pack of beer a week. His uncle also has gout, and the patient asks what his risk factors are that can influence the severity of gout. The correct response is: A Family history B Age C Alcohol use D Asthma
C
A 35-year-old man presents to an urgent care clinic with signs and symptoms consistent with acute gouty arthritis of his right ankle. Uric acid crystals are found in the aspirated articular fluid from the ankle. He has a history of poorly controlled dyslipidemia and drinks three beers nightly. He is an avid runner and reports eating fruits, vegetables, and low-fat dairy products. Which of the following sets of characteristics are risk factors for gout in this patient? A Male sex and intense physical activity B Consumption of alcohol and low-fat dairy products C Dyslipidemia and alcohol consumption D Age and consumption of low-fat dairy products E Dyslipidemia and age
Answer: D Option A: Incorrect. Although titration of febuxostat is recommended to control the patient's hyperuricemia, the addition of colchicine is only indicated if given within 36 hours of attack onset. Option B: Incorrect. While the addition of naproxen is preferred therapy for pain and inflammation during an acute attack, the patient also requires titration of urate-lowering therapy (ie, febuxostat) to address hyperuricemia. Option C: Incorrect. The patient requires titration of urate-lowering therapy (ie, febuxostat) to address hyperuricemia; the addition of colchicine is only indicated if given within 36 hours of attack onset. Option D: Correct. Titration of febuxostat will address the patient's hyperuricemia, while addition of naproxen is preferred therapy for the pain and inflammation during an acute attack.
A 42-year-old woman presents to her family physician 48 hours after the onset of her third acute gout flare this year with complaints of severe pain and swelling of her left knee. She is taking febuxostat 40 mg once daily (initiated last month) and her serum uric acid today is 9.6 mg/dL (571 μmol/L). Except for gout, her past medical history is unremarkable, and she is adherent to current therapy. What do you recommend to optimize the patient's pharmacotherapy regimen? A Increase febuxostat to 80 mg daily and add colchicine for acute treatment followed by anti-inflammatory prophylaxis. B Continue febuxostat 40 mg daily and add naproxen for acute treatment followed by anti-inflammatory prophylaxis. C Continue febuxostat 40 mg daily and add colchicine for acute treatment followed by anti-inflammatory prophylaxis. D Increase febuxostat to 80 mg daily and add naproxen for acute treatment followed by anti-inflammatory prophylaxis.
Answer: B Option A: Incorrect. Although lesinurad can lower uric acid, it is never recommended as monotherapy and must always be combined with either allopurinol or febuxostat. Option B: Correct. Febuxostat is a xanthine oxidase inhibitor and considered first-line for urate lowering. It can also be used safely in mild renal impairment. Option C: Incorrect. While naproxen is successful in treating acute gout flares due to its anti-inflammatory properties, it is not effective in lowering the uric acid level. Option D: Incorrect. Allopurinol is considered first-line for urate lowering; however, given the patient's history of allopurinol hypersensitivity syndrome, it is not the safest option.
A 45-year-old woman presents to clinic for routine follow-up after an acute gout attack. She has experienced three flares within the past 8 months treated successfully with NSAIDs. Her past medical history includes mild renal impairment and allopurinol hypersensitivity syndrome. Based on her past medical history, what agent would be the most appropriate to initiate for chronic urate lowering? A Lesinurad B Febuxostat C Naproxen D Allopurinol
A
A 55-year-old man is newly diagnosed with gout and hyperuricemia. His past medical history is significant for type 2 diabetes, dyslipidemia, and hypertension, all well controlled. Medications include atorvastatin 40 mg at bedtime, niacin 1000 mg at bedtime, lisinopril 10 mg daily, metformin 500 mg twice daily, and aspirin 81 mg daily. He does not meet criteria for urate-lowering therapy, and the physician wishes to implement other antihyperuricemic measures. What is the best recommendation? A Consider changing lisinopril to losartan. B Add fenofibrate to current lipid-lowering therapy. C Consider changing lisinopril to hydrochlorothiazide. D Discontinue aspirin 81 mg daily. E Increase niacin to 1500 mg at bedtime.
Answer: D Option A: Incorrect. Probenecid is not an appropriate initial therapy. Option B: Incorrect. Febuxostat is no longer considered first-line, but rather an alternative to allopurinol. Option C: Incorrect. Colchicine is not a urate-lowering therapy. Option D: Correct. Allopurinol is an appropriate first-line therapy for this patient.
A 55-year-old woman presents to clinic after her fourth acute gout flare within the past 12 months. She is currently taking naproxen, and the healthcare team would like to initiate urate-lowering therapy. Her past medical history includes chronic kidney disease stage 3, diastolic heart failure, and chronic obstructive pulmonary disease. What agent would be the most appropriate to initiate for chronic urate lowering? A Probenecid B Febuxostat C Colchicine D Allopurinol
Answer: B Option A: Incorrect. Losartan is preferred since it increases both uric acid excretion and urine pH and may be an option in hypertensive patients with gout in place of lisinopril for blood pressure lowering. Option B: Correct. Although fenofibrate is uricosuric, it is conditionally recommended against in patients with gout who need cholesterol-lowering therapy. Statins remain the choice for cholesterol-lowering treatment due to their cardiovascular protective effects. Option C: Incorrect. Thiazide diuretics can worsen hyperuricemia and precipitate gout. Option D: Incorrect. Patients with hyperuricemia and gout and cardiovascular risk factors should continue low-dose aspirin for heart attack or stroke prevention because the cardiovascular benefit outweighs the minimal effect on serum urate levels
A 59-year-old man is diagnosed with gout and hyperuricemia. His past medical history is significant for type 2 diabetes, dyslipidemia, and hypertension. Medications include fenofibrate 145 mg daily, losartan 50 mg daily, metformin 500 mg twice daily, and aspirin 81 mg daily. He does not meet criteria for urate-lowering therapy, and the physician wishes to implement other antihyperuricemic measures. Given this information, what is the best recommendation for treatment modification? A Consider changing losartan to lisinopril. B Consider changing fenofibrate to a statin. C Consider changing losartan to hydrochlorothiazide. D Discontinue aspirin 81 mg daily.
Answer: D Option A: Incorrect. Although NSAIDs can be used with caution in patients with controlled hypertension, they can still cause fluid retention leading to elevated blood pressure. Option B: Incorrect. The recommended regimen for acute gout treatment is 150 to 200 mg orally two times daily for 7 to 10 days. Option C: Incorrect. It is generally recommended to continue NSAIDs at full doses until 24 hours after symptoms subside. Option D: Correct. NSAIDs can cause GI, renal, and cardiovascular adverse effects.
A 62-year-old woman presents with newly diagnosed gout. Her medical history is significant for controlled hypertension and prediabetes. She takes amlodipine 10 mg daily. Sulindac is initiated for acute gout management. What counseling should be provided to the patient regarding sulindac therapy? A Sulindac use will not impact any of your other medical conditions. B Sulindac 150 mg orally once daily for 3 days is recommended. C You may discontinue sulindac immediately upon symptom resolution. D Adverse effects may include stomach problems, kidney impairment, and fluid retention.
Answer d is correct. This would be an option for patients who have contraindications to other acute gout therapy, such as nonsteroidal anti-inflammatory drugs (NSAIDs) with peptic ulcer disease. Answers a and b are incorrect. They are both NSAIDs and should be avoided in patients with a history of peptic ulcer disease. Answer c is incorrect.Allopurinol should not be initiated as treatment for an acute gout flare as this medication may worsen the flare by rapidly decreasing uric acid and causing mobilization of uric acid stores.
A 63-year-old man presents to your clinic complaining of excruciating pain in his left big toe. After being diagnosed with an acute gout flare, his physician wants to start him on therapy. His medical history is positive for hypertension, hyperlipidemia, peptic ulcer disease, and glaucoma. Which of the following is the most appropriate therapy at this time for the patient? A Ibuprofen B Indomethacin C Allopurinol D Prednisone
Answer a is correct.Allopurinol is used for chronic prophylaxis of gout in patients who are overproducers of uric acid. Answer b is incorrect.Febuxostat should not be used in hepatic impairment. Answers c and d are incorrect. These agents are used in underexcretors of uric acid, not overproducers.
A 68-year-old man presents to the clinic with a history of three acute episodes of gout in the past year. He is classified as an overproducer of uric acid. He has severe liver impairment but no renal insufficiency. Which of the following medications is appropriate for chronic prophylaxis of gout? A Allopurinol B Febuxostat C Probenecid D Sulfinpyrazone
Answer: B Option A: Incorrect. Although probenecid is considered an alternate first-line agent if xanthine oxidase inhibitor (XOI) therapy is either not tolerated or contraindicated, it loses its effectiveness as renal function declines and should be avoided when the CrCl is 50 mL/min (0.83 mL/s) or less. Option B: Correct. Patients with a mild skin rash who require allopurinol can be safely desensitized to it using published protocols. Option C: Incorrect. Febuxostat is not recommended for patients with severe renal insufficiency (CrCl < 30 mL/min [0.5 mL/s]). Option D: Incorrect. Pegloticase is generally reserved for refractory cases due to the inconvenience of dosing via IV infusion.
A 70-year-old patient with chronic gout develops a mild maculopapular rash 1 week after initiating allopurinol therapy, and alternative therapy to lower his SUA is considered. His past medical history is significant for hypertension, obesity, and chronic kidney disease (last estimated creatinine clearance 25 mL/min [0.42 mL/s]). Which one of the following statements is true concerning this case? A Probenecid would be an appropriate choice for treatment of chronic gout. B Allopurinol desensitization could be attempted in this patient. C High-dose febuxostat would be needed to reach SUA goals in this patient. D The dose and schedule of pegloticase would be the most convenient option for the patient.
Answer: B Option A: Incorrect. Opioid analgesics have been shown to have minimal benefit in providing rapid relief to severe acute gout attacks. Option B: Correct. Oral, intra-articular, and intramuscular glucocorticoids are options for patients experiencing an acute gout flare since the patient has taken colchicine and ibuprofen already. Option C: Incorrect. Xanthine oxidase inhibitors will not provide rapid relief in severe acute gout attacks. Option D: Incorrect. Uricosurics will not provide rapid relief in severe acute gout attacks.
A 75-year-old man presents to the emergency department reporting severe elbow pain. He has a diagnosis of gout and is currently on allopurinol 800 mg daily and colchicine 1.2 mg daily. Prior to coming to the emergency department, he tried taking ibuprofen 800 mg for the pain and reports that it has not relieved his pain. Which of the following drug classes can provide rapid relief for this patient's severe acute gout attack? A Opioids B Glucocorticoids C Xanthine oxidase inhibitors D Uricosurics
Answer c is correct. Tophi are painful MSU crystals which deposit in the skin and can cause tissue damage. These complications often occur in patients with long-standing hyperuricemia and chronic gout. Answer a is incorrect. Atheroma is a lipid deposit within the arterial wall and is not related to gout. Answer b is incorrect. Podagra is a term used to describe gout-related symptoms in the great toe. Answer d is incorrect. Uric acid nephrolithiasis is a complication of gout characterized by MSU crystal deposits in the kidney which can contribute to renal failure.
A 76-year-old woman with a 10-year history of gout presents to the clinic with painful monosodium uric (MSU) crystal deposits in her hand. Which of the following terms most accurately describes this complication of gout? A Atheromas B Podagra C Tophi D Uric acid nephrolithiasis
Answer a is correct. The major side effects which can limit the use of colchicine are gastrointestinal. Answer b is incorrect. This would be a counseling point for allopurinol. Answer c is incorrect. This would be a counseling point for nonsteroidal anti-inflammatory drugs (NSAIDs). Answer d is incorrect. This would be a counseling point for corticosteroids.
A patient is picking up a new prescription for colchicine. Select the most appropriate counseling point to discuss with the patient. A The patient should be counseled on gastrointestinal side effects of nausea, vomiting, diarrhea, and abdominal pain. B The patient should be counseled on the possibility of a rash. C The patient should be counseled on signs and symptoms of bleeding. D The patient should be counseled on close monitoring of blood glucose levels.
Answer: A Option A: Correct. Applying ice packs to the joint is the most effective nonpharmacologic way to decrease pain and swelling, whereas use of NSAIDs at the higher end of the therapeutic range is generally the preferred pharmacologic treatment of choice for an acute attack. Option B: Incorrect. While immobilization of the affected extremity speeds resolution of the attack, use of compression hose is not recommended due to lack of beneficial evidence. Option C: Incorrect. Massaging the joint with movement may exacerbate symptoms; however, applying ice packs to the joint is the most effective nonpharmacologic way to decrease pain and swelling, Option D: Incorrect. Although use of NSAIDs at the higher end of the therapeutic range is generally preferred as the pharmacologic treatment of choice for an acute attack, heat application may be detrimental.
A patient presents to the emergency department and a diagnosis of an acute gout attack is made. She reports having taken ibuprofen for pain relief and application of ice, a compression stocking, and massaging the area, with some improvement in symptoms. Following stabilization and prior to discharge from the emergency department, what measures should you advise the patient are most helpful in providing pain relief and speeding attack resolution? A Application of ice and use of high-dose ibuprofen B Compression hose applied to the affected area and rest C Brisk massage and movement of the affected area and application of ice D High-dose ibuprofen and application of heat
Answer: C Option A: Incorrect. Use of low-dose NSAIDs is not associated with reduction in the development of complications related to longstanding hyperuricemia because they do not lower uric acid levels in the body. Option B: Incorrect. Doses at the higher end of the therapeutic range are often needed to adequately manage an acute attack. Option C: Correct. Initiation of urate-lowering therapy (ULT) may precipitate or exacerbate gouty arthritis. Guidelines recommend that when ULT is started all acute gout patients should receive prophylaxis with colchicine or a low-dose NSAID and acid-suppressing therapy. Option D: Incorrect. The rationale for use is discussed under option C above.
A patient was recently initiated on low-dose naproxen therapy with omeprazole to prevent GI adverse effects. Why would this type of regimen be warranted in a patient with gout? A Prevention of the complications of tophi and nephrolithiasis. B Anti-inflammatory treatment for an acute attack. C Anti-inflammatory prophylaxis during initiation of urate-lowering therapy. D This regimen does not have a place in therapy for the management of gout.
Answer: B Option A: Incorrect. Pegloticase is generally reserved for treatment of refractory cases of gout. Option B: Correct. Pegloticase is contraindicated in patients with G6PD deficiency due to the risk of hemolysis and methemoglobinemia; therefore, patients should be screened prior to initiation of therapy. Option C: Incorrect. Significant adverse effects, including gout flares, infusion reactions, and anaphylaxis mandate pretreatment with antihistamines and glucocorticoids, not proton pump inhibitors (ie, omeprazole). Option D: Incorrect. Combination therapy with pegloticase and allopurinol is not indicated to prevent rebound gouty flares.
A patient with a history of severe chronic gout, including multiple tophi and uric acid nephropathy, is being considered for pegloticase therapy because other treatments have failed to lower the SUA to goal. His past medical history is significant for hypertension, asthma, and dyslipidemia. He smokes one pack of cigarettes daily and works as a long-haul truck driver. Which one of the following statements is true concerning this case? A Pegloticase would not be expected to be effective if other standard treatments have failed. B The patient should be screened for G6PD deficiency prior to initiation. C If pegloticase is initiated, the patient should be premedicated with fexofenadine and omeprazole prior to the infusion. D Pegloticase should be used in combination with allopurinol to prevent rebound gouty flares.
B
A patient with gout has recently been started on allopurinol and is undergoing dose titration. What laboratory test should be monitored at monthly follow-up visits during this period? A Urinalysis B Serum urate C Serum creatinine D Aspartate aminotransferase E No routine lab monitoring is required
Answer: C Option A: Incorrect. Type 2 diabetes mellitus does not increase the risk of developing allopurinol hypersensitivity syndrome. Option B: Incorrect. Hypertension does not predispose a patient to developing the allopurinol hypersensitivity syndrome. Option C: Correct. Concurrent therapy with thiazide diuretics and allopurinol increases the risk of allopurinol hypersensitivity syndrome. Option D: Incorrect. Concurrent therapy with metformin and allopurinol does not increase the risk of allopurinol hypersensitivity syndrome.
A prescriber would like to initiate allopurinol in a 60-year-old woman newly diagnosed with gout in the primary care clinic. Past medical history includes hypertension, type 2 diabetes mellitus, and eczema. Home medications include hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, and metformin 1000 mg twice daily. Which of the following increases her chances of developing allopurinol hypersensitivity syndrome? A Mild renal impairment B Hypertension C Hydrochlorothiazide D Eczema
Answer: D Option A: Incorrect. Febuxostat is associated with an increased risk of cardiovascular disease. Option B: Incorrect. Colchicine is not an appropriate add-on for hyperuricemia. Option C: Incorrect. Pegloticase is last-line urate-lowering therapy for severe gout. Option D: Correct. Probenecid is appropriate for this patient since he does not have chronic kidney disease stage 3 or greater.
An adult man has been on allopurinol 400 mg twice daily for chronic urate lowering for the past 3 years; however, his serum uric acid (SUA) remains consistently above 6 mg/dL (357 μmol/L) with occasional acute gout attacks. He has a past medical history of CKD stage 2, hypothyroidism, hypertension, and type 1 diabetes mellitus. The provider is concerned about his risk of cardiovascular disease. What change in therapy is most appropriate to improve hyperuricemia and long-term disease control? A Add febuxostat B Add colchicine C Add pegloticase D Add probenecid
Answer: C Option A: Incorrect. The combination of allopurinol and febuxostat would be considered duplicate therapy since both are xanthine oxidase inhibitors. Option B: Incorrect. The addition of lesinurad to allopurinol in patients with normal renal function who have failed to achieve their uric acid target is only appropriate with doses of 300 mg or greater. Option C: Correct. The allopurinol dose should be gradually increased (to a maximum of 800 mg/day) to achieve the target SUA level. Option D: Incorrect. While prednisone is successful in treating acute gout flares due to its anti-inflammatory properties, it is not effective for chronic urate lowering.
An adult man with normal renal function has been maintained on allopurinol 200 mg daily for chronic urate lowering for the past three years; however, his serum uric acid (SUA) remains consistently above target with occasional acute gout attacks. What change in therapy is most appropriate to improve hyperuricemia and long-term disease control? A Add febuxostat B Add lesinurad C Increase the allopurinol dose D Add prednisone
A
An emergency department physician asks you why a lower dose of colchicine is now recommended for treatment of acute gout flares compared to when she went to medical school. What is your response? A The lower dosage regimen is associated with fewer gastrointestinal adverse effects. B Although the lower dose of colchicine is less effective, it is also safer and thus preferred. C Since most patients with gout are taking allopurinol, the chance of a drug interaction is less if the lower dose of colchicine is used. D The lower dose of colchicine is associated with less liver toxicity.
A
An emergency room physician asks you why a lower dose of colchicine is now recommended for treatment of acute gout flares. What is your response? A The lower dosage regimen is associated with fewer gastrointestinal adverse effects. B Although the lower dose of colchicine is less effective, it is also safer and thus preferred. C Since most patients with gout are taking allopurinol, the chance of a drug interaction is less if the lower dose of colchicine is used. D The lower dose of colchicine is associated with less liver toxicity. E None of the above responses are correct.
Answer a is correct. Corticosteroids are the drugs of choice for acute gout in patients with renal insufficiency. Answers b and c are incorrect. They are both nonsteroidal anti-inflammatory drugs (NSAIDs) and should be avoided in patients with a history of renal dysfunction. Answer d is incorrect.Colchicine should be avoided in patients with severe renal insufficiency (CrCl <10 mL/min) due to increased risk for toxicities.
In a patient with a creatinine clearance (CrCl) of less than 10 mL/min, which acute gout medication is most appropriate? A Prednisone B Ibuprofen C Nabumetone D Colchicine
E
In which patient population should HLA-B*5801 screening be considered prior to allopurinol initiation? A Routine screening is recommended for all patients B Patients of Korean descent with stage 2 or worse chronic kidney disease C Patients with a history of Stevens-Johnson syndrome D Caucasian patients with chronic kidney disease E All patients of Thai descent
nswer a is correct. Red meats, particularly organ meats, have high purine content and should be avoided in patients with gout. Answers b, c, and d are incorrect. These foods have low purine content.
JJ is a patient who is receiving medication therapy management services from your pharmacy. Since he has a past medical history of gout, which of the following foods should you counsel him to avoid eating as it contains a high purine content? A Liver B Apple C Popcorn D Potatoes
C Answer a is incorrect. In this scenario, the urgent care clinic provider may not be aware of the patient's recent GI bleed and chronic kidney disease. Therefore, it would be best to verify this with the provider prior to filling the prescription. An NSAID in this particular patient case would not be the best option. Answer b is incorrect. This is not the best answer because although it would be important to verify with the provider regarding the risk from the recent GI bleed and that the patient possibly might be covered with the PPI, the patient also has a history of chronic kidney disease, so an NSAID would not be desirable in this case. Answer c is correct. Due to this patient's history of a recent GI bleed and chronic kidney disease, an NSAID is not the best choice of treatment and carries a lot of risk, even if the patient is taking a PPI to help with the bleeding risk. A corticosteroid would be the best option for patients who have a history of a recent GI bleed and history of renal dysfunction. Answer d is incorrect.Colchicine is not a good option for this patient, as they have chronic kidney disease and more information regarding their renal impairment would be needed to assess, as well as information regarding how long it has been since the onset.
Question 15 of 17 A 72-year-old man presents to your community pharmacy to pick up a new prescription for indomethacin. It was prescribed by an urgent care clinic for an acute gout attack in his left knee. After reviewing his medication profile, you see that he is also being treated for a recent gastrointestinal (GI) bleed with a proton pump inhibitor (PPI) prescribed by a GI specialist. His past medical history also includes hypertension, type 2 diabetes, and chronic kidney disease. What is the best course of action to take? A Fill the script as the patient is currently being covered by a PPI. B Contact the prescriber to verify that they were aware of the patient's past medical history and discuss if they want to continue the nonsteroidal anti-inflammatory drug (NSAID) therapy. C Contact the prescriber to verify that they were aware of the patient's past medical history and recommend to switch the patient to a corticosteroid D Contact the prescriber to verify that they were aware of the patient's past medical history and recommend to switch the patient to colchicine
A
Select the target serum uric acid (SUA) level when treating gout. A ≤6 mg/dL B ≤7 mg/dL C ≤8 mg/dL D ≤9 mg/dL
nswer c is correct.Probenecid blocks reuptake of uric acid at the proximal tubule Answer a is incorrect. This is the mechanism of action of allopurinol and febuxostat. Answer b is incorrect.Probenecid increases uric acid excretion. Answer d is incorrect. This is the mechanism of action of NSAIDs.
What is the mechanism of action by which probenecid produces its effect? A Inhibition of xanthine oxidase B Blocks excretion of uric acid C Blocks reuptake of uric acid at the proximal tubule D Inhibits prostaglandin synthesis
Answer: D Option A: Incorrect. See justification for option D below. Option B: Incorrect. While it is imperative to assess serum creatinine and estimate creatinine clearance to determine an appropriate starting dose of allopurinol, additional screening is also warranted due to the patient's ethnicity. Option C: Incorrect. While pharmacogenetic screening via human leukocyte antigen (HLA)-B*5801 testing is recommended for patients at an elevated risk for allopurinol hypersensitivity syndrome (AHS), which includes all individuals of Thai descent, additional laboratory testing is also warranted to determine the patient's creatinine clearance given the history of CKD. Option D: Correct. Prior to initiating allopurinol, pharmacogenetic screening via human leukocyte antigen (HLA)-B*5801 testing is recommended for patients at an elevated risk for AHS, which includes all individuals of Thai descent. Additionally, given the patient's history of CKD, it is imperative to assess serum creatinine and estimate creatinine clearance to determine an appropriate allopurinol starting dose.
What laboratory tests and screenings should be performed in a 67-year-old Taiwanese woman with CKD prior to allopurinol initiation? A No routine laboratory tests or screenings are recommended. B Serum creatinine only C HLA-B*5801 only D Serum creatinine and HLA-B*5801 screening
C
What would be an appropriate starting dose of allopurinol in a 55-year-old man with gout and chronic kidney disease if his serum creatinine is 2.1 mg/dL (186 μmol/L)? He is 5'7" (170 cm) and weighs 75 kg (165 lb). A 50 mg daily B 100 mg every other day C 100 mg daily D 300 mg daily E Allopurinol is not recommended in patients with chronic kidney disease
Answer c is correct. Colchicine is a National Institute for Occupational Safety and Health (NIOSH) group 3 medication that recommends the use of single gloves for handling tablets.
Which agent has special handling precautions? A Allopurinol B Febuxostat C Colchicine D Prednisone
The correct answer is A. You answered A. Explanation: Answer a is correct. This medication is only available as an intravenous formulation. Answer b is incorrect.Allopurinol has both an oral and intravenous formulation. Answer c is incorrect.Colchicine is only available in an oral formulation. Answer d is incorrect.Prednisone is only available in oral formulations (alternative steroids may have intravenous options).
Which agent is only available as an injectable? A Pegloticase B Allopurinol C Colchicine D Prednisone
B
Which combination regimen is inappropriate for managing severe pain during an acute gouty attack? A Colchicine + NSAID B NSAID + oral corticosteroid C Colchicine + oral corticosteroid D Oral corticosteroid + intraarticular corticosteroid E NSAID + intraarticular corticosteroid
Answer: B Option A: Incorrect. Although the ACR supports the use of colchicine with an NSAID for severe polyarticular attacks, colchicine interacts with strong 3A4 inhibitors like clarithromycin leading to an increased risk of colchicine toxicity, and cotherapy is contraindicated. Option B: Correct. The ACR supports the use of an oral corticosteroid with an intraarticular corticosteroid for severe polyarticular attacks because they work systemically and locally, respectively, and although clarithromycin may potentially increase prednisone levels leading to side effects, their coadministration is not contraindicated. Option C: Incorrect. Although the ACR supports the use of colchicine with an oral corticosteroid for severe polyarticular attacks, colchicine interacts with strong 3A4 inhibitors like clarithromycin leading to an increased risk of colchicine toxicity, and cotherapy is contraindicated. Option D: Incorrect. The ACR does not recommend the combination of a NSAID and oral corticosteroid likely due to the similar nature of their systemic affects and increased risk for toxicity.
Which combination regimen is the most appropriate and safest for managing severe pain during an acute gouty attack in a patient who is taking a course of clarithromycin for an infection? A Oral colchicine + oral NSAID B Oral corticosteroid + intraarticular corticosteroid C Oral colchicine + oral corticosteroid D Oral NSAID + oral corticosteroid
Answer: B Option A: Incorrect. Although the American College of Rheumatology (ACR) supports use of colchicine with an NSAID for severe polyarticular attacks, colchicine interacts with strong 3A4 inhibitors like clarithromycin leading to an increased risk of colchicine toxicity, and cotherapy is contraindicated. Option B: Correct. The ACR supports the use of an oral glucocorticoid with an intra-articular glucocorticoid for severe polyarticular attacks because they work systemically and locally, respectively, and although clarithromycin may potentially increase prednisone levels leading to side effects, their coadministration is not contraindicated. Option C: Incorrect. Although the ACR supports use of colchicine with an oral glucocorticoid for severe polyarticular attacks, colchicine interacts with strong 3A4 inhibitors like clarithromycin leading to an increased risk of colchicine toxicity, and cotherapy is contraindicated. Option D: Incorrect. The ACR does not recommend the combination of a NSAID and oral glucocorticoid likely due to the similar nature of their systemic affects and increased risk for toxicity.
Which combination regimen is the most appropriate and safest for managing severe pain during an acute gouty attack in a patient who is taking a course of clarithromycin for an infection? A Oral colchicine + oral NSAID B Oral glucocorticoid + intra-articular glucocorticoid C Oral colchicine + oral glucocorticoid D Oral NSAID + oral glucocorticoid
Answer a is correct. Use of allopurinol may inhibit the metabolism of warfarin and theophylline, resulting in increased levels of each drug. Answers b, c, and d are incorrect.Allopurinol may inhibit the metabolism of warfarin and theophylline, resulting in increased levels of each drug versus decreased levels.
Which of the following is a true statement regarding allopurinol drug interactions? A Use of allopurinol increases warfarin levels and increases theophylline levels. B Use of allopurinol increases warfarin levels and decreases theophylline levels. C Use of allopurinol decreases warfarin levels and decreases theophylline levels. D Use of allopurinol decreases warfarin levels and increases theophylline levels.
B
Which one of the following nonpharmacologic measures may be helpful in providing pain relief from an acute gouty attack? A Application of heat B Application of ice C Compression hose applied to the affected area D Increased oral intake of water E Brisk massage of the affected area
A
Which one of the following patients should be considered for initiation of urate-lowering therapy? A A patient experiencing his first acute attack with multiple tophi on his knee. B A patient experiencing his first acute attack with stage 1 chronic kidney disease. C An asymptomatic patient with a serum uric acid (SUA) of 15 mg/dL (892 μmol/L). D A patient after resolution of a severe second attack of gout in the past 2 years. E A patient with a strong family history of gout who is started on niacin therap
C
Which one of the following statements concerning febuxostat in the treatment of gout is correct? A It is more effective in reducing acute gouty flares than allopurinol titrated to the serum uric acid (SUA) target. B It should not be used in patients with a history of allopurinol hypersensitivity syndrome. C Liver function tests should be monitored when initiating and titrating therapy. D Combination therapy with allopurinol and febuxostat can achieve greater decreases in SUA than either agent alone. E Febuxostat should be avoided in patients with mild-to-moderate renal impairment.
Answer: C Option A: Incorrect. Most studies have shown similar efficacy among NSAIDs. Option B: Incorrect. Indomethacin is available generically and at relatively low cost; however, it should be avoided due to safety issues. Option C: Correct. Indomethacin's relative COX-1 selectivity increases its gastropathy risk. Studies comparing indomethacin to other NSAIDs consistency show similar efficacy with higher side effects; thus, other generic NSAIDs may be preferred. Option D: Incorrect. NSAIDs have largely replaced colchicine as the treatment of choice for acute gout.
Which one of the following statements concerning indomethacin use in acute gout is correct? A Studies have determined that indomethacin is the most effective NSAID in acute gout. B Indomethacin should be avoided because of its high cost relative to other NSAIDs. C Other NSAIDs may be as effective as indomethacin in acute gout with more favorable safety profiles. D Colchicine is more effective than indomethacin in acute gout.
D
Which one of the following statements is true regarding anti-inflammatory prophylaxis during initiation of urate-lowering therapy? A It is not recommended during initiation of allopurinol therapy in patients with renal insufficiency. B Colchicine 1.2 mg orally for one dose followed by 0.6 mg 1 hour later is the recommended first-line regimen. C Naproxen is less likely to cause renal insufficiency than other NSAIDs for anti-inflammatory prophylaxis. D Low-dose NSAID therapy should be combined with acid suppression therapy to prevent GI adverse effects. E Low-dose prednisone is the recommended first-line therapy for anti-inflammatory prophylaxis.
Answer c is correct.Febuxostat is metabolized through the liver and is an option for patients with renal insufficiency. Answer a is incorrect.Febuxostat is metabolized through the liver and should not be used in liver failure. Answer b is incorrect.Febuxostat is used as treatment in chronic gout. Answer d is incorrect.Febuxostat does interact with drugs, including azathioprine, 6-mercaptopurine, and theophylline.
Which statement is true regarding febuxostat? A Febuxostat is a good choice for patients with liver failure. B Febuxostat is the drug of choice for acute gout. C Febuxostat is an option for patients with renal insufficiency. D Febuxostat has no drug interactions.
Answer c is correct. NSAIDs work by exerting anti-inflammatory, analgesic, and antipyretic effects by inhibiting the synthesis of prostaglandin. Answers a, b, and d are incorrect. This is the mechanism of action of colchicine, allopurinol, and probenecid, respectively.
Which statement most accurately describes the mechanism of nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of gout? A NSAIDs work by reducing phagocytosis and lactic acid production in joints, thereby reducing deposition of urate crystals. B NSAIDs work by blocking the conversion of xanthine to uric acid. C NSAIDs work by exerting anti-inflammatory, analgesic, and antipyretic effects by inhibiting the synthesis of prostaglandin. D NSAIDs work by inhibiting proximal renal tubule reabsorption of uric acid to decrease serum levels.
nswer b is correct. Short-acting NSAIDs at anti-inflammatory doses are indicated for acute gout in the absence of contraindications. Answer a is incorrect. Any NSAID used at anti-inflammatory doses can be efficacious for the treatment of gout. Answer c is incorrect. Fast-acting oral administration is usually preferred. Answer d is incorrect.Colchicine would not be preferred over NSAIDs due to the onset being greater than 36 hours.
You are on the internal medicine rounding service and taking care of a patient who has developed an acute gouty arthritis flare, with an onset 48 hours ago. The resident physician on your team would like to start the patient on a nonsteroidal anti-inflammatory drug (NSAID). Which of the following is a true statement regarding the use of NSAIDs in the treatment of gout and should be communicated to the resident physician? A Indomethacin is the NSAID of choice for treating gout. B Short-acting NSAIDs at anti-inflammatory doses are indicated for acute gout in the absence of contraindications. C Intravenous administration is the preferred route of administration when using NSAIDs for the treatment of gout. D Colchicine would be preferred to NSAIDs for the acute treatment of gout in this patient.
Answer a is incorrect. All nonsteroidal anti-inflammatory drugs (NSAIDs) have the same primary mechanism of action. Answer b is incorrect. The half-life of a medication demonstrates the length of effect, which correlates most with how frequently to dose the medication. This frequency does not specifically make a medication more or less favorable for gout flare treatment. Answer c is incorrect. At equipotent anti-inflammatory doses the bioavailability of each agent should not impact effectiveness. Answer d is correct.Indomethacin has a faster onset of action, providing quicker relief of acute pain (Indomethacin: onset 30 minutes with a peak at 2 hours, Diclofenac sodium onset around 2 hours with peak effect at 3-5 hours).
n comparison to diclofenac sodium, what makes indomethacin a preferred agent for use in gout flares? A Mechanism of action B Half-life C Bioavailability D Onset of action
