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19 Cards in this Set
- Front
- Back
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Refer to case (a) for this:
Which of the following suggest that patient’s symptoms might be caused by an attack of gouty arthritis? a. Acute onset of excruciating pain in the left ankle, interrupting sleep and affecting mobility b. Elevated white blood cell count, erythrocyte sedimentation rate, and serum uric acid concentration c. History of peptic ulcer disease d. A and B e. All of the above |
d.
There is no relationship between peptic ulcer disease and gout. Answers A and B describe characteristic signs and symptoms associated with Gout (slides 24 and 33) |
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Refer to case (a) for this:
What factors might have precipitated this patient’s gouty attack? a. Niacin (Niaspan) b. Omeprazole (Prilosec) c. Consumption of wine d. All of the above |
a.
Niacin is a common cause of drug-induced hyperuricemia and gout. (Slide 15) Omeprazole and wine do not cause hyperuricemia or Gout. Beer and liquor cause hyperuricemia but not wine. (Slide 57) |
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Refer to case (a) for this:
Which of the following treatments would be most useful to treat the patient’s acute attack. a. Ibuprofen 800 mg four times per day b. Colchicine 0.6 mg now and ever hour until side effects occur or pain subsides c. Probenecid 250 mg twice daily d. Allopurinol 300 mg once daily |
b.
. Ibuprofen should not be administered to patients with PUD or other risk factors placing them at high risk for bleeding. (Slide 41 and 51). Allopurinol and Probenecid are urate-lowering drugs and should not be used to treat an acute attack |
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Which of the following would indicate the need for uric-acid lowering therapy in a patient with hyperuricemia and gout?
I. Multiple recurrent attacks II. Evidence of tophi III. Uric acid > 7.0 mg/dL before treatment a. I b. II c. III d. I and II e. II and III |
d.
Multiple attacks and the presence of tophi warrant Uric acid-lowering therapy. UA> 11.0 without treatment or >7.0 during treatment indicates the need for UA-lowering therapy. (Slide 59) |
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Which of the following medications used to treat gout/hyperuricemia can be safely and effectively used without the need for dosage adjustment in patients with kidney disease?
a. allopurinol (Alloprim) b. probenecid (Benemid) c. prednisone d. naproxen (Aleve) |
c.
Corticosteroids are a safe and effective option in patients with acute gout complicated by renal insufficiency. (Slide 53) NSAIDs can cause acute renal failure and allopurinol and colchicine must be dose adjusted and used with caution. (Slides 53, 56, and 65) |
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DC, a 57-year-old male (height = 66 inches, weight = 228 lb), presents to your clinic
complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for atrial fibrillation, uncontrolled hypertension, type 2 diabetes mellitus, chronic renal insufficiency, and dyslipidemia. Upon examination, it is determined that several other joints are involved, including his right ankle and left knee. He is eventually diagnosed with polyarticular gout. His current medications include enalapril, metoprolol, HCTZ, low-dose aspirin, glipizide, ranitidine, and niacin. Initial labs are significant only for the following Uric acid = 10.8 mg/dl SCr = 2.1 mg/dL Which of DC’s medications have been implicated as a drug-induced cause of hyperuricemia? a. Niacin b. Hydrochlorothiazide c. Enalapril d. All of the above e. A and B |
e.
Both niacin and HCTZ increase serum uric acid levels. Low dose aspirin would as well. Enalapril has not been shown to increase serum uric acid |
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DC, a 57-year-old male (height = 66 inches, weight = 228 lb), presents to your clinic
complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for atrial fibrillation, uncontrolled hypertension, type 2 diabetes mellitus, chronic renal insufficiency, and dyslipidemia. Upon examination, it is determined that several other joints are involved, including his right ankle and left knee. He is eventually diagnosed with polyarticular gout. His current medications include enalapril, metoprolol, HCTZ, low-dose aspirin, glipizide, ranitidine, and niacin. Initial labs are significant only for the following Uric acid = 10.8 mg/dl SCr = 2.1 mg/dL Which of the following represents the most appropriate first line treatment of this patient’s acute gouty attack? a. Colchicine 1.2 mg once, followed by 0.6 mg every hour until symptom resolution or adverse events occur b. Naproxen 375-500mg PO BID for 3 days, then 250-375mg BID for 3 days c. Prednisone 60 mg QD for 2 days, 30 mg QD for 2 days, 20 mg QD for 4 days d. Triamcinolone 20 mg administered intraarticularly to affected metatarsaphalangeal joint |
a.
Because of a narrow therapeutic window, potential for severe adverse effects, poor tolerability and the availability of other equally effective alternatives, colchicine is generally reserved for patients who are not considered candidates for NSAIDs. This patient has uncontrolled hypertension and chronic renal insufficiency, thus naproxen should be avoided. Systemic corticosteroids are reserved only for those patients not responding/tolerating other agents due to poor tolerability and potential for significant adverse effects. Intraarticular triamcinolone will provide relief only for the injected joint and thus should be reserved for monoarticular gouty attacks [objs. 4 and 5, slides 41-50] |
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DC recovers from the initial acute gouty attack, but experiences 2 additional attacks over the next 7 months. The serum uric acid level is 11.2 mg/dL several months after the last
attack. The patient undergoes a 24-hour urine collection and 950 mg of uric acid is recovered in the patient’s urine. What is the most appropriate treatment for this patient’s hyperuricemia? a. Place the patient on a purine-restricted diet and recheck UA in 3 months b. Start probenecid 250 mg PO BID and gradually titrate to UA < 6.0 mg/dL c. Start sulfinpyrazone 50 mg PO BID and gradually titrate to UA < 6.0 mg/dL d. Start allopurinol 100 mg QD and gradually titrate to UA < 6.0 mg/dL e. Start allopurinol 300 mg QD and gradually titrate to UA < 6.0 mg/dL |
d.
In this patient with recurrent attacks and serum uric acid above 11.0 mg/dL, pharmacological uric acid-lowering is indicated. In general, even the most diligent patient will be able to reduce their uric acid by approximately 1 mg/dl. Uricosurics should be avoided when UA excretion is high (>700 mg/24 hours,) and they are ineffective when renal insufficiency is present. Because the patient had excessive (>700mg/d) uric acid in the urine, one can assume that the patient is an over-producer of uric acid. Thus, uric acid-lowering therapy should target production (i.e., allopurinol). Allopurinol works, however, regardless of etiology. The correctly adjusted dose of allopurinol for the patient’s renal function (~55 mL/min) is 100 mg/d. The dose can then be advanced slowly as necessary to achieve goal uric acid level. |
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Which of the following is most correct regarding the pharmacotherapy of gout?
a. Allopurinol lowers uric acid only when overproduction is the cause of hyperuricemia b. Probenecid is effective for treating hyperuricemia only when underexcretion is the cause c. Uric acid-lowering therapy should be initiated as early as possible once an acute gouty attack is detected d. Indomethacin is the ideal NSAID for treating acute gouty attacks e. ACTH is the drug of choice for treating acute gouty attacks in patients receiving systemic corticosteroids |
b.
Allopurinol is the uric acid-lowering agent of choice, regardless of etiology. The uricosurics probenecid and sulfinpyrazone are only useful in the setting of documented underexcretion of urate. There is nothing special about indomethacin. In fact, it is poorly tolerated, even compared with other NSAIDs, and has a greater depressor effect on GFR. ACTH is ineffective in patients on corticosteroids chronically. [objs. 1, 3, 4 and 5 various slides] |
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A 57-year-old male (height = 66 inches, weight = 228 lb) presents to your clinic
complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for uncontrolled hypertension, type 2 diabetes mellitus, diabetic nephropathy, and dyslipidemia. His current medications include enalapril, metoprolol, HCTZ, low-dose aspirin, glipizide, ranitidine, and nicotinic acid. Initial labs are significant for the following Uric acid = 10.8 mg/dl SCr = 1.9 Which of the following represents the most appropriate first line treatment for this patient? a. Colchicine 1.2 mg Q 1 hour until pain relief or diarrhea b. Celecoxib 400mg once, then 200 mg daily for 7 days c. Naproxen 375-500mg PO BID for 3 days, then 250-375mg BID for 3 days d. Prednisone 60 mg QD for 2 days, 30 mg QD for 2 days, 20 mg QD for 4 days |
d.
Given the considerable side effect profile of corticosteroids, they are reserved for patients ineligible for or intolerant of other options. In this case, the patient is ineligible for other therapies, thus corticosteroids are the best answer |
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A 57-year-old male (height = 66 inches, weight = 228 lb) presents to your clinic
complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for uncontrolled hypertension, type 2 diabetes mellitus, diabetic nephropathy, and dyslipidemia. His current medications include enalapril, metoprolol, HCTZ, low-dose aspirin, glipizide, ranitidine, and nicotinic acid. Initial labs are significant for the following Uric acid = 10.8 mg/dl SCr = 1.9 The patient recovers from the initial acute gouty attack, but experiences 2 additional attacks over the next 7 months. The UA level is found to be 9.2 mg/dL several months after the last attack. The patient undergoes a 24-hour urine collection and 950 mg of uric acid is recovered in the patient’s urine. What is the most appropriate treatment for this patient? a. Start probenecid 250 mg PO BID and gradually titrate to UA < 6.0 mg/dL to decrease risk of gouty attacks b. Place the patient on a purine-restricted diet and recheck UA in 3 months c. Discontinue drugs that are likely to be contributing to hyperuricemia d. Start allopurinol 100 mg QAM and recheck UA in 3 months e. Start allopurinol 300 mg QAM and recheck UA in 3 months |
d.
Because the patient had excessive (>700 mg/d) uric acid in the urine, one can assume that the patient is an over-producer of uric acid. Thus, uric acid-lowering therapy should target production (i.e., allopurinol). Allopurinol would work, however, regardless of etiology. This dose is correctly adjusted for the patient’s reduced renal function |
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A 57-year-old male (height = 66 inches, weight = 228 lb) presents to your clinic
complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for uncontrolled hypertension, type 2 diabetes mellitus, diabetic nephropathy, and dyslipidemia. His current medications include enalapril, metoprolol, HCTZ, low-dose aspirin, glipizide, ranitidine, and nicotinic acid. Initial labs are significant for the following Uric acid = 10.8 mg/dl SCr = 1.9 Which of the following patient’s medications would most likely increase the risk of recurrent gout? a. Enalapril b. Nicotinic acid c. Glipizide d. Ranitidine |
b.
Niacin increases uric acid levels and can precipitate gout. |
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Which of the following is NOT true regarding the pharmacotherapy of gout?
a. Patients receiving colchicine chronically should be monitored for muscle weakness and bone marrow suppression b. Probenecid effectively lowers uric acid in patients that overproduce urate c. Uric acid-lowering therapy should be withheld during the acute gouty attack. d. In patients without tophi, uric acid should be lowered < 6.0 mg/dl to decrease the likelihood of recurrent attacks. e. Indomethacin is markedly more effective in the management of acute gouty attacks than any other NSAID. |
b.
Probenecid increases urate excretion and is not effective in patients that overproduce urate |
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A 57-year-old male (height = 66 inches, weight = 228 lb) presents to your clinic complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for hypertension, type 2 diabetes mellitus, atrial fibrillation, and dyslipidemia. His current medications include enalapril, HCTZ, low-dose aspirin, glipizide, warfarin, and nicotinic acid.
Initial labs are significant for the following Uric acid (UA) = 10.8 mg/dl SCr = 1.3 Which of the following represents most appropriate treatment for this patient? a. Colchicine 0.6 mg Q 1 hour for 3 hours b. Celecoxib 400mg once, then 200 mg daily for 7 days c. Naproxen 375-500mg PO BID for 3 days, then 250-375mg BID for 3 days d. Prednisone 60 mg QD for 2 days, 30 mg QD for 2 days, 20 mg QD for 4 days |
a.
Because of a narrow therapeutic window, potential for severe adverse effects, poor tolerability and the availability of other equally effective alternatives, colchicine is not a first line agent. However, because this patient is on an oral anticoagulant, colchicine is a reasonable selection to avoid drug interactions (eg., with NSAIDs). |
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Which of the following is most accurate regarding the pharmacotherapy of gout?
a. When uric acid lowering therapy is indicated, uricosurics or xanthine oxidase inhibitors should be started during an acute gouty attack to decrease the risk of recurrent attacks b. When uric acid lowering therapy is indicated, uricosurics should be administered to patients with hyperuricosuria (>700 mg/dL) c. When uric acid lowering therapy is indicated, xanthine oxidase inhibitors should be administered to patients with hyperuricosuria (>700 mg/dL) d. When anti-inflamatory therapy is indicated, indomethacin is the NSAID of choice to treat acute exacerbations of gout |
c.
Hyperuricosuria suggests overproduction and when indicated, allopurinol is the drug of choice |
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DG has gout. During subsequent clinic visits DG’s blood pressure is noted to be 150 – 160/95 – 105 mmHg and his physician wishes to add another antihypertensive medication to his pharmacotherapeutic regimen. Which of the following is most likely to exacerbate this patient’s gout and/or hyperuricemia?
a. hydrochlorothiazide (Esidrix, others) b. lisinopril (Zestril, Prinivil) c. metoprolol (Lopressor) d. diltiazem (Cardizem, Cartia, others) |
a.
thiazide and loop diuretics decrease elimination of uric acid |
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A 57-year-old male (height = 66 inches, weight = 228 lb) presents to your clinic complaining of excruciating pain and erythema in the right foot affecting the 1st metatarsaphalangeal joint. The pain began last night just before the patient fell asleep. His medical history is significant for hypertension, type 2 diabetes mellitus, and dyslipidemia. His current medications include losartan (Cozaar), hydrochlorothiazide (Esidrix, others), low-dose aspirin, glipizide (Glucotrol), simvastatin (Zocor) and gemfibrozil (Lopid).
Initial labs are significant for the following Uric acid = 10.8 mg/dl SCr = 1.3 Which of the following represents the appropriate first line treatment for this patient? a. Colchicine 1.2 mg PO once, then 0.6 mg Q 1 hour until pain resolves or adverse effects occur b. Celecoxib (Celebrex) 400mg once, then 200 mg daily for 7 days c. Naproxen (Naprosyn) 375-500mg PO BID for 3 days, then 250-375mg BID for 3 days d. Prednisone 60 mg QD for 2 days, 30 mg QD for 2 days, 20 mg QD for 4 days |
c. Naproxen (Naprosyn) 375-500mg PO BID for 3 days, then 250-375mg BID for 3 days
Nonselective NSAIDs are effective and inexpensive for treating acute episodes of gout. Used episodically for acute attacks they have a favorable safety profile as well. |
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After the acute gouty attack resolves, the patient is started on sulfinpyrazone (Anturane) 50 mg BID and is titrated to 200 mg BID. The response is inadequate (uric acid =9.8) and the patient suffers from 2 recurrent gouty attacks over the next 9 months. A 24-hour uric acid is collected. 950 mg of uric acid were recovered in the patient’s urine.
2. What is the most appropriate treatment for this patient? a. Continue sulfinpyrazone (Anturane) and start colchicines 0.6 mg BID b. Discontinue sulfinpyrazone (Anturane) and place the patient on a purine-restricted diet c. Discontinue sulfinpyrazone (Anturane) and start probenecid (Benemid) 250 mg BID d. Discontinue sulfinpyrazone (Anturane) and start allopurinol (Zyloprim) 300 mg QD |
d. Discontinue sulfinpyrazone (Anturane) and start allopurinol (Zyloprim) 300 mg QD
Because the patient had excessive (>700 mg/d) uric acid in the urine, one can assume that the patient is an over-producer of uric acid. Thus, uric acid-lowering therapy should target production (i.e., allopurinol). |
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Also, during a subsequent visit DG informs you that his insurance program will no longer pay for gemfibrozil (Lopid). Which of the following alternative agents would be the least beneficial substitute for gemfibrozil (Lopid) for this patient?
a. niacin (Niaspan) b. ezetimibe (Zetia) c. atorvastatin (Lipitor) d. fenofibrate (Tricor) |
a. niacin (Niaspan)
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