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Old 11-18-2012
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Arrow Billy Step 1 Questions # 87

A 50-year-old slightly obese man comes to the emergency department with his wife at 3 am complaining of severe pain in his left great toe. He said the pain began 5 hours ago while he was walking home after dinner, which consisted of steak and a few beers. His serum studies are unremarkable except for negative blood cultures and an elevated uric acid level. When asked about allergies, the patient states that he is allergic to nonsteroidal anti-infl ammatory drugs. An aspiration of the toe reveals negatively birefringent crystals. Which of the following is the best acute treatment for this condition?


(A) Allopurinol
(B) Ceftriaxone
(C) Colchicine
(D) Hydrochlorothiazide
(E) Ibuprofen
(F) Indomethacin
(G) Naproxen
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Old 11-18-2012
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Default my answer :)

(C) Colchicine
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Old 11-18-2012
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Default G?

Not sure here
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Old 11-18-2012
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the answer is colchicine

The first line drugs for acute gout are colchicine and potent NSAIDS like Indomethacin. Colchicine is the classic drug used in acute gout and it has no other use as far as I can remember. Since it associated with prominent gastrointestinal symptoms the trend is shifting to use of NSAIDs these days. Since the person is allergic to NSAIDS, we should give colchicine.

a. Allopurinol is a Xanthine Oxidase Inhibitor used in chronic gout. Its use in acute gout would rather exacerbate the condition.

b. Ceftriaxone would be ineffective here as it is not septic arthritis

d. Hydrochlorothiazide causes hyperuricemia and would exacerbate the condition

e,f,g: Ibuprofen, Indomethacin and Naproxen are all NSAIDS that our patient is allergic to

PS: I liked the history given. It is filled with conditions that cause precipitation of acute gout.
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Old 11-18-2012
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Colchicine. If the patient were not allergic to NSAIDs, then I would choose Indomethacin.
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Old 11-19-2012
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C) Colchicine
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Old 11-19-2012
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Correct Answer C is correct

Gout is characterized by a raised blood uric acid level that leads to uric acid deposition in tissues, particularly the joints. In some patients, gout is precipitated by eating foods rich in purine, such as meats (especially organ meats, like kidneys). The first-line therapy in the treatment of gout consists of non steroidal anti-infl ammatory drugs (NSAIDs) such as ibuprofen, naproxen, and indomethacin. However, since the patient is allergic to NSAIDs, colchicine is the next best therapy for an acute gouty attack. It is considered an alternate drug because adverse effects include diarrhea, gastrointestinal upset, and (in patients with renal or hepatic insuffi ciency) bone marrow suppression, myopathy, and neuropathy. Colchicine works by inhibiting microtubule polymerization by binding to tubulin, one of the main constituents of microtubules. This inhibits immune cell motility and activity, thus promoting an anti-inflammatory result.
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