CG is a 67 year old male (5'10"; 90kg) who presents to the emergency department early in the morning after awakening with severe throbbing right toe pain that was similar to pain he had several years ago. He has NKDA with a past medical history significant for heart failure (ejection fraction 35%), hypertension, atrial fibrillation, peptic ulcer disease, GERD, and hypothyroidism. His current medications include lisinopril 20mg daily, furosemide 40mg daily, carvedilol 12.5mg BID, omeprazole 20mg daily, apixaban 5mg BID, and levothyroxine 100mcg daily. Vital signs include blood pressure of 135/85, pulse 75, temperature 99.9F, and respiratory rate of 14. Chem-7 is within normal limits.
Which of the following would be the most appropriate agent for treating CG's acute gout attack?
A. Colchicine 1.2mg now following by one repeat 0.6mg dose if needed 1 hour later
B. Naproxen 500mg twice daily
C. Allopurinol 300mg daily
D. Prednisone 60mg daily for 3-5 days
E. Febuxostat 80mg daily
Answer with rationale: The correct answer is A. The key to answering this question correctly is understanding drug-disease contraindications. Gout therapies in 2019 can be grouped into two primary categories: Acute therapies and prophylactic therapies. This eliminates answers C and E immediately as these are agents used to prevent gout attacks long-term, not treat an acute gout attack. Long-term CG may require prophylactic therapy due to his daily furosemide therapy which can increase his risk for gout attacks.
That leaves answers A, B and D. All 3 of these therapies are excellent agents for treating acute gout. However, CG has two disease states of note: systolic heart failure and peptic ulcer disease. Both of these disease states are not good for NSAID or corticosteroid therapy. Therefore this eliminates answers B and D leaving answer A.
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