Gout

Question 1

A patient is post-op from surgery. The patient has a history of gout. While performing a head-to-toe assessment, you assess the patient for signs and symptoms of gout. You know that gout tends to start at what site?
A.) Ball and socket joint
B.) Pivot joint 
C.) Metatarsophalangeal joint
D.) Saddle joint

Answer 1

C 
big toe (metatarsophalangeal joint)

Question 2

Uric acid is the end product of \_\_\_\_\_ metabolism?
A.) pyrimidines
B.) purines
C.) adenine
D.) thymine

Answer 2

B

Purines—> UA—->urine (excretion)

Question 3

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

Answer 3

A

Red meats, particularly organ meats, have high purine content and should be avoided in patients with gout.

Question 4

A 76-year-old woman with a 10-year history of gout presents to the clinic with painful 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

Answer 4

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.

Question 5

A pharmacist is going to counsel a patient beginning allopurinol therapy. Which counseling statement should be included?
A. This medication should be taken on an empty stomach.
B. Allopurinol can cause blood pressure changes; hold onto the bed or rail when changing from a sitting to a standing position.
C. If the patient notices a rash, contact a physician at once. If the rash looks serious, the patient should not use the medicine and should be seen right away.
D. This medication should only be administered in a medical office.
E. The brand name of this medication is Colcrys.

Answer 5

C

HLA-B*5801 testing prior to use due to risk of SJS/TEN.

Question 6

Which of the following are risk factors for the development of gout? (Select ALL that apply.)
A. Hypertension
B. Renal insufficiency
C. Advanced age
D. Obesity
E. Excessive alcohol consumption

Answer 6

ALL

Question 7

A patient is having an acute gout attack. As an alternative to colchicine, which of the following treatment options can be recommended to help treat the acute pain and inflammation? (Select ALL that apply.)
A. Febuxostat
B. Naproxen
C. Allopurinol
D. Prednisone
E. Ibuprofen

Answer 7

B, D, E

Acute attacks could be treated with colchicine, NSAIDs, or steroids.

Question 8

John Deer is a 54 year-old male with hypertension and renal insufficiency. He presents to the clinic with severe pain and a very swollen big toe. Mr. Deer is diagnosed with gout, and given a ten-day prescription for prednisone. Which of the following are short-term side effects from the use of prednisone? (Select ALL that apply.)
A. Possible blood sugar elevation
B. Feeling "spacey" or irritable
C. Cushingoid side effects
D. Hypotension
E. Insomnia

Answer 8

A, B, E

Short term side effects of steroids:

1. ) ↑BP, glucose, appetite
2. ) weight gain
3. ) emotional instability
4. ) Insomnia

Long-term side effects of steroids:
Cushing syndrome

Question 9

Uricosuric agents such as probenecid lower uric acid levels in the body by increasing the elimination of uric acid. These agents are not useful in many patients with gout since they require adequate:
A. Liver function
B. Renal function
C. Pulmonary function
D. Adherence
E. None of the above; probenecid is the drug of choice for most patients with gout who require a daily medication to lower uric acid.

Answer 9

B

Question 10

What is the rationale in using colchicine or an NSAID while beginning allopurinol therapy?
A. To reduce the risk of an acute flare
B. To reduce the risk of renal damage
C. To reduce the risk of mild or severe rash
D. To reduce the risk of crystallization in the urine
E. None of the above

Answer 10

A.
It sounds counter-intuitive, but when beginning a potent agent such as allopurinol to lower uric acid, the patient may get an acute flare.

Question 11

Which analgesic should not be recommended to help with the pain of an acute gout attack as it may increase uric acid levels?
A. Bufferin
B. Ibuprofen
C. Naproxen
D. Sulindac
E. Celecoxib

Answer 11

A
Bufferin is low dose aspirin.

Remember drugs that worsen gout:
LOW dos aspirin
Diuretics (loops/thiazides)
Niacin
Pyrazinamide (RIPE regimen)
CNIs

Question 12

Once a gout attack occurs, drugs are used to treat the acute attack and prevent future attacks, which requires lowering the UA level to  
A.) 5
B.) 6
C.) 7
D.) 3

Answer 12

B

<6 mg/dl

Question 13

To reduce the risk of recurrent gout attacks what food should the patient avoid? (Select all)
A.) Organ meats
B.) Alcohol
C.) Whole grains 
D.) High-fructose corn syrup

Answer 13

A, B (especially beer), D

Question 14

Which of the following drugs must be used in combination with an Xanthine Oxidase Inhibitor? 
A.) Febuxostat 
B.) Lesinurad 
C.) Pegloticase
D.) Probenecid

Answer 14

B

Lesinurad must be used with an XOI (allopurinol or febuxostat) if UA goals are not reached with XOI alone.

Question 15

Which of the following is NOT a first-line option for the pharmacologic treatment of acute gout?

A. NSAIDs

B. Corticosteroids

C. Oral colchicine

D. Low dose aspirin

Answer 15

D

High dose NSAIDs should be used to treat gout attacks:

1. ) Indomethacin (Indocin)
2. ) Naproxen
3. ) Sulindac
4. ) Celecoxib

However, remember NSAIDs should be avoided in patients with severe renal disease, CVD risk, and bleeding.

Question 16

Which of the following is the recommended first-line urate-lowering therapy to consider?

A. Febuxostat

B. Allopurinol

C. Probenecid

D. Benzbromarone

Answer 16

B

Question 17

During a home health visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid:
A. Sardines 
B. Whole wheat bread
C. Sweetbreads 
D. Crackers
E. Craft beer 
F. Bananas

Answer 17

The answers are A, C, and E.

A patient with gout should avoid foods high in PURINES. These include most red meats, organ meats (liver, kidneys, sweetbreads), alcohol (especially beer).

Question 18

Identify which patient below is at MOST risk for developing gout:
A. A 56 year old male who reports consuming foods low in purines.
B. A 45 year old male with a BMI of 40 who reports taking hydrochlorothiazide and aspirin.
C. A 39 year old female hospitalized with bulimia that has a BMI of 24.
D. A 27 year old female with ulcerative colitis.

Answer 18

B

Gout is due to high levels of uric acid in the blood. Some causes that can lead to increased uric acid levels include: being overweight (BMI >25 is considered overweight), usage of aspirin or diuretics (thiazides (hydrochlorothiazide) or loop), HIGH consumption of purines, dehydration, renal problems.

Question 19

Your patient reports to you that he is having muscle pain and tingling in his fingers and toes. You note that the patient also has a grayish color to his lips. You immediately notify the doctor. Which gout medication was he taking? 
A. Ibuprofen
B. Prednisone
C. Colchicine
D. Aspirin

Answer 19

C

The signs and symptoms presenting in this patient are classic signs of Colchicine toxicity. This medication can also cause GI upset and neutropenia.

Question 20

It is important a patient with gout avoid medications that can increase uric acid levels. Which medication below is NOT known to increase uric acid levels?
A. Aspirin
B. Niacin
C. Cyclosporine
D. Tylenol

Answer 20

D