Examkin

Question

Difficulty: HardPharmacologic Interventions

A 52-year-old man visits the clinic due to sudden, severe pain and swelling in his right big toe that began overnight. He is unable to bear weight on the affected foot. His medical history is significant for a deceased-donor renal allograft performed three years ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His current medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are within normal limits. Physical examination reveals a swollen, erythematous, and exquisitely tender right first metatarsophalangeal joint. Joint aspiration is performed, and synovial fluid analysis reveals negatively birefringent, needle-shaped crystals under polarized light microscopy. His serum creatinine today is 1.6 mg/dL, which is unchanged from his baseline over the past year. Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

  1. Intra-articular triamcinoloneAnswer
  2. B
    Oral colchicine
  3. C
    Oral naproxen
  4. D
    Oral allopurinol
  5. E
    Intravenous ceftriaxone and vancomycin

Answer

Intra-articular triamcinolone is the most appropriate intervention for this patient.
Intra-articular triamcinolone is the safest and most effective therapy for acute monoarticular gout in a renal transplant recipient. By utilizing a localized injection, the physician avoids systemic drug interactions and nephrotoxicity while providing rapid, targeted symptomatic relief in a single joint.

Step-by-Step Solution

1
Analyze the clinical presentation and synovial fluid results.
The patient has an acute flare of monoarticular gout, definitively confirmed by the presence of negatively birefringent, needle-shaped crystals.
Establishing an accurate diagnosis is the essential first step before selecting targeted therapy, ruling out infectious etiologies.
2
Evaluate the patient's comorbidities and current medication list.
The patient is a renal transplant recipient with baseline chronic kidney disease, currently taking immunosuppressants including tacrolimus (a calcineurin inhibitor).
Comorbidities and immunosuppressive regimens significantly restrict standard pharmacological options due to the high risk of organ toxicity and severe drug-drug interactions.
3
Select the safest targeted therapy for acute gout based on the patient's constraints.
Intra-articular triamcinolone is chosen because standard first-line therapies (NSAIDs and colchicine) are strictly contraindicated in this specific clinical context.
NSAIDs exacerbate calcineurin inhibitor nephrotoxicity, and colchicine clearance is fatally impaired by tacrolimus-mediated P-glycoprotein and CYP3A4 inhibition. A local corticosteroid injection provides effective relief without these systemic risks.

Key Concept

Pharmacologic management of acute gout in solid organ transplant recipients requires avoiding NSAIDs (due to nephrotoxicity) and colchicine (due to severe pharmacokinetic interactions with calcineurin inhibitors), making intra-articular glucocorticoids the preferred choice for monoarticular flares.
Rate this question

Topics

Pharmacologic Interventions

More questions from this topic