NAPLEX - Gout McGraw Hill

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

A

.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.

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

A

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.

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.

C

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 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.

C

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.

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.

B

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.

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

C

.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.

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

A

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.

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.

A

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.

Consider the following statements regarding the administration of corticosteroids for the treatment of an acute gout attack. Select all that are true.

A

Corticosteroids can be administered orally or via intra-articular injection.

B

Use of intra-articular injections are reserved for when synovial fluid analysis of the joint can rule out infection.

C

Oral administration is recommended for sites not available to aspiration.

D

Intra-articular injections are best for severe oligoarticular or polyarticular attacks.

ABC

Corticosteroids can be administered orally or via intra-articular injection. However, use of intra-articular injections is reserved for when synovial fluid analysis of the joint can rule out infection. Oral administration is recommended for sites not available to aspiration

Answer d is incorrect. If a patient has severe oligoarticular or polyarticular attacks, it is recommended to administer corticosteroids orally.

Which of the following statements describes allopurinol dosing and its role in gout prevention? Select all that apply.

A

Allopurinol is most effective when initiated within 24 to 48 hours of an acute attack.

B

The usual starting dose is 100 mg po daily.

C

Allopurinol is traditionally a chronic medication once initiated.

D

Serious side effects include myopathy and bone marrow suppression.

BC

Initiation of treatment with allopurinol 100 mg and titrated based on serum uric acid (SUA) levels.

Answer c is correct.Allopurinol is used for chronic management and should be continued long-term until talking to your provider.

Answer a is incorrect.Allopurinol should not be started during an acute flare as it has the potential to exacerbate the flare.

Answer d is incorrect. These are side effects reported with colchicine.

A 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

A

The antihypertensive hydrochlorothiazide can contribute to hyperuricemia, and if possible, it should be avoided in patients with gout.

remember thiazides, loops incr UA, TG/LDL, BG

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.

Which of the following is/are appropriate therapies for an acute gout attack? Select all that apply.

A

Probenecid

B

Colchicine

C

Sulindac

D

Febuxostat

BC

.Colchicine may be utilized for acute gout flares.

Answer c is correct.Sulindac (nonsteroidal anti-inflammatory drug [NSAID]) may be utilized for acute gout flares.

Answers a is incorrect.Probenecid should be reserved for chronic treatment of gout.

Answer d is incorrect.Febuxostat should be reserved for chronic treatment of gout.

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

C

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 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

D

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.

Which of the following brand name therapies are approved for chronic management of gout? Select all that apply.

A

Uloric

B

Zyloprim

C

Zebeta

D

Indocin

AB

Uloric (febuxostat) is a urate-lowering therapy used for chronic gout management.

Answer b is correct. Zyloprim (allopurinol) is a urate-lowering therapy used for chronic gout management.

Answer c is incorrect. Zebeta (bisoprolol) is a β-blocker with no impact on gout therapy.

Answer d is incorrect. Indocin (indomethacin) is a nonsteroidal anti-inflammatory drug (NSAID) used for treatment of acute gout flares. It may also be used for prophylaxis when starting urate-lowering therapy until achievement of appropriate uric acid targets.

Which agent has special handling precautions?

A

Allopurinol

B

Febuxostat

C

Colchicine

D

Prednisone

C

Colchicine is a National Institute for Occupational Safety and Health (NIOSH) group 3 medication that recommends the use of single gloves for handling tablets.

Answer a, b, and d are incorrect. These three agents do not have unique handling requirements.

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.

A

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.

A resident physician approaches you about a patient admitted for an acute gout flare. He wants to start the patient on nonsteroidal anti-inflammatory drug (NSAID) therapy. Which of the following would be important to communicate to the resident regarding monitoring parameters? Select all that apply.

A

Recommend to monitor serum creatinine for renal dysfunction.

B

Recommend to monitor blood glucose levels.

C

Recommend to monitor for diarrhea.

D

Recommend to monitor for signs of bleeding.

AD

Patients with gout may have a worsening of renal dysfunction with the use of NSAIDs and NSAIDs should be avoided if renal dysfunction is present at baseline.

Answer d is correct. It would be important to monitor for this possible side effect. Gastrointestinal (GI) intolerance is common and the most severe aspect of this would be an acute GI bleed.

Answer b is incorrect. It is important to monitor blood glucose levels in patients who are started on corticosteroid therapy—regardless if patients are diabetic or not, due to corticosteroid's ability to increase blood glucose levels.

Answer c is incorrect. This would be an important monitoring parameter if the patient was started on colchicine.

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

C

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.

Which of the following measures are appropriate recommendations in a 75-year-old patient with gout? Select all that apply.

A

Weight loss

B

Reduction of alcohol consumption

C

Application of cold packs

D

Application of heat

ABC

Weight loss, reduction of alcohol, and application of cold packs are utilized in the management of gout.

Answer d is incorrect. The affected joints should be rested and treated with cold packs (application of heat should be avoided).

Which agent is only available as an injectable?

A

Pegloticase

B

Allopurinol

C

Colchicine

D

Prednisone

A

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).

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

A

The target SUA level should be ≤6.

Answers b, c, and d are incorrect. Target SUA level should be ≤6.

Which of the following is consistent with the typical clinical presentation of gout? Select all that apply.

A

Commonly affects the great toe

B

Bilateral joint involvement

C

Rapid onset of symptoms

D

Self-limiting pain and erythema

ACD

Patients with gout frequently present with rapid onset of self-limiting pain and erythema, commonly involving the great toe.

Answer b is incorrect. Gout is typically a monoarthritis and is usually not characterized by bilateral joint involvement.

In 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

D

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).