NAPLEX Question of the Week: Gauging the Gout

A common painful condition is the subject of our question of the week!
NAPLEX Question of the Week: Gauging the Gout
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PJ is a 67-year-old male presenting to urgent care with a swollen, red, and tender ankle. He states a pain score of 5 (moderate pain) and explains that his ankle pain work him up in the middle of last night. His physician determines he is having an acute gout attack. PJ’s physician asks for your recommendation to treat his acute gout attack.

Past Medical History: Type 2 Diabetes, Hyperlipidemia

Allergies: NKA

Meds: Metformin 1000mg BID, Atorvastatin 40mg daily

Vitals: 

Heart Rate: 65bpm  Blood Pressure: 127/82mmHg  Weight: 80kg  Height: 5’10”  Temperature: 99.6 F

Labs: 

Na 137 mEq/L  K 4.1 mEq/L  Cl 98 mEq/L  SCr 0.9 mg/dL  A1c 6.8%  FBG: 100mg/dL  Uric Acid: 8.5mg/dL

Which of the following medications would be appropriate choices for this patient’s acute gout attack? Select All That Apply. 

A. Colcrys

B. Indocin

C. Allopurinol

D. Uloric

E. Naproxen

Brands/Generics:

Colcrys/Colchicine; Indocin Indomethacin; Allopurinol/Zyloprim; Febuxostat,Uloric;  Aleve/Naproxen

Answers with Rationale: 

Gout is an inflammatory disease state of the joints associated with elevated uric acid levels. It is characterized by recurrent attacks of acute arthritis associated with urate crystals in the fluid of the joint. This can present as pain, tenderness, swelling, and redness in joints.

Choice A is correct. PJ stated his symptoms started in the middle of the night which prompted his visit to urgent care first thing in AM. Colcrys is the first line recommendation for an acute gout attack if it is within 36 hours of symptom onset and some guidelines state optimally within 12 hours. Colchicine is a first line agent for treating gout attacks. 

Choice B is an appropriate option for this patient’s gout attack as it is an appropriate NSAID (the three most common options being indomethacin, sulindac, and naproxen), which is a good first line option for an acute gout attack. Monotherapy is appropriate for this patient, as he is in moderate pain with only one large joint involved. This patient does not have contraindications or allergies preventing its use. 

Choices C and D are not correct. Urate lowering therapy (ULT), including allopurinol (Xyloprim) and Febuxostat (Uloric), should not be started during an acute gout attack. Initiation during a gout attack can cause an exacerbation of the attack. ULT should only be started in patients with 1 attack if they have CKD (stage 3 or greater), serum urate concentration >9 mg/dL, or urolithiasis. If a patient is indicated for ULT, it should not be started until after the attack has resolved. ULT should be taken concomitantly with anti inflammatory prophylaxis for 3-6 months. 

Choice E is an appropriate option for this patient’s gout attack as it is also an appropriate NSAID (the three most common options being indomethacin, sulindac, and naproxen), which is a good first line choice for an acute gout attack. Monotherapy is appropriate for this patient, as he is in moderate pain with only one large joint involved. This patient does not have contraindications or allergies preventing its use. 

In summary, the correct answer choices are A, B and E.

NAPLEX Competencies Covered: 

Area 1: Obtain, Interpret, or Assess Data, Medical, or Patient Information

1.1 From instruments, screening tools, laboratory, genomic or genetic information, or diagnostic findings

Area 2: Identify Drug Characteristics 

2.1 Pharmacology, mechanism of action, or therapeutic class

2.2 Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied 

Area 3: Develop or Manage Treatment Plans 

3.3 Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions 

3.6 Drug contraindications, allergies, or precautions

3.11 Evidence-based practice  

The exam is closing in! Only about two months away from graduation! Keep up the hard work! See you next week!

Dr. B

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