JR is a 58 year-old-male with Southeast Asian descent who comes into your ambulatory care clinic just a few days after he went to an urgent care for complaints of pain and inflammation in his right great toe. The physician at the urgent care concluded that this was another gout flare for JR and prescribed naproxen and Colcrys to help with the acute gout flare. 

PMH: Hypertension, allergic rhinitis, acute gout flares

Labs:

Uric acid: 9.2 mg/dL (2.5-7.0 mg/dL)

CrCl: 89 mL/min

Vitals:

HR: 86 bpm

BP: 132/84 mmHg

Weight: 91 kg

Height: 71 inches

Medications:

Colcrys 1.2 mg PO then 0.6 mg 1 hour later 

Naproxen 750 mg PO once then 250 mg Q8H for 5 days

Amlodipine 5 mg PO QD

Xyzal 5 mg PO QD

You are considering recommending Zyloprim therapy due to this being JR’s third gout flare this year. Which of the following are correct regarding this potential therapy? Select all that apply.

A. JR may be an increased risk for a fatal hypersensitivity reaction with Zyloprim compared to the general population

B. Recommend lifestyle changes such as reduction in alcohol intake, purine intake, and high fructose syrup intake along with Zyloprim

C. Recommend pegloticase over Zyloprim due to this being JR’s third gout flare this year.

D. Overlap Colcrys 0.6 mg PO daily with Zyloprim for several months

E. JR should be screened for G6PD deficiency prior to decrease the risk of hemolytic anemia 

Gout is a spectrum of diseases that revolves around elevated serum urate (uric acid) concentrations with crystal formation within joint(s). Manifestations include: recurrent attacks of acute arthritis associated with urate crystals in synovial joint fluid, deposits of urate crystals in tissues and joints, and uric acid nephrolithiasis (kidney stones). Gout is known as the disease of kings because it has historically been associated with high income lifestyles; prevalence of gout is highest in high income countries. Lifestyle risk factors include obesity, high alcohol intake, red meat intake, and sugar intake.

Answer A is correct: Allopurinol hypersensitivity syndrome is a very rare adverse effect associated with allopurinol (Zyloprim) that has a mortality rate of 20-25%. Those with the HLA-B*5801 allele are more likely to have this reaction, and patients with Southeast Asian descent along with African Americans have a higher risk for having this allele. While testing is expensive, his risk is elevated compared to the general population and would be very reasonable. 

Answer B is correct: Lifestyle modifications are always recommended in preventing gout flare ups in conjunction with any medication therapy. 

Answer C is incorrect: Pegloticase is never used 1st line in urate lowering therapy. Also having 2 or more gout flares in one year is one indication for beginning urate lowering therapy in general.

Answer D is correct: Whenever urate lowering therapy is first started, prophylactic therapy is indicated to decrease the risk of an acute gout flare. Prophylactic therapy is generally for 3-6 months, and typical agents are colchicine, NSAIDs, or prednisone.

Answer E is incorrect: This is correct for Kyrstexxa (pegloticase) which has a boxed warning for increased risk of hemolysis or methemoglobinemia. Pegloticase would be contraindicated in anyone found to be G6PD deficient. 

Brand/Generics Covered:

Colchicine (Colcrys), naproxen (Naprosyn), amlodipine (Norvasc), levocetirizine (Xyzal), pegloticase (Krystexxa)

NAPLEX Competencies Covered:

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

1.4 - From medical records: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background

1.5 - Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology

1.6 - Risk factors or maintenance of health and wellness

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 

3.4 - Drug dosing or dosing adjustments; duration of therapy

3.5 - Drug route of administration, dosage forms, or delivery systems

3.6 - Drug contraindications, allergies, or precautions

3.7 - Adverse drug effects, toxicology, or overdose

3.9 - Therapeutic monitoring parameters, monitoring techniques, monitoring tools, or monitoring frequency

3.11 - Evidence based practice

3.12 - Non-drug therapy: lifestyle, self-care, first-aid, complementary and alternative medicine, or medical equipment