A 71-year-old man presents to an urgent care clinic with sudden-onset, severe pain in his … — USMLE Step 3

A 71-year-old man presents to an urgent care clinic with sudden-onset, severe pain in his right foot that awakened him from sleep. The patient states the pain is so intense that he cannot tolerate a bedsheet touching his foot. His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$ , chronic kidney disease, and type 2 diabetes mellitus. His daily medications are sacubitril-valsartan, carvedilol, empagliflozin, and torsemide. Vital signs include a blood pressure of $108/65\text{ mm Hg}$ , heart rate of $72/\text{min}$ , and temperature of $37.4^\circ\text{C}$ ( $99.3^\circ\text{F}$ ). Physical examination reveals a visibly swollen, distinctly erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Laboratory studies show:

Leukocyte count: $11,200/\text{mm}^3$
Serum uric acid: $8.8\text{ mg/dL}$
Serum creatinine: $2.3\text{ mg/dL}$ (baseline $1.5\text{ mg/dL}$ )

Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute joint symptoms?

Oral prednisoneCevap
B
Oral indomethacin
C
Oral colchicine
D
Oral allopurinol
E
Intravenous ceftriaxone

Cevap

The most appropriate initial intervention is oral prednisone, as it effectively treats the acute gout flare while avoiding the renal and cardiac toxicities associated with other first-line agents.

The correct answer is oral prednisone. This patient presents with podagra, the classic manifestation of an acute gout flare. Standard first-line therapies for acute gout include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or systemic glucocorticoids. The selection among these agents must be individualized based on the patient's comorbidities. This patient has evidence of an acute kidney injury (creatinine increased from

1.5\text{ mg/dL}

2.3\text{ mg/dL}

) and a history of heart failure with reduced ejection fraction. NSAIDs are absolutely contraindicated because they inhibit afferent arteriolar vasodilation, which will worsen his kidney injury, and they promote sodium retention, which can trigger acute decompensated heart failure. Colchicine is highly dependent on renal clearance; administering standard doses in the setting of an acute, severe decline in renal function poses a high risk for potentially fatal toxicities, including neuromyopathy and cytopenias. Therefore, a short course of systemic glucocorticoids (such as oral prednisone) is the safest and most appropriate pharmacologic intervention to resolve the acute joint inflammation.

Adım Adım Çözüm

Diagnose the acute condition based on the clinical presentation.

The patient is experiencing an acute gout flare (podagra).

Sudden onset of exquisitely tender, erythematous, and swollen first metatarsophalangeal joint is the classic clinical presentation of gout.

Identify relevant comorbidities and current organ function that affect pharmacotherapy.

The patient has heart failure with reduced ejection fraction (

30\%

) and acute kidney injury (creatinine elevated to

2.3\text{ mg/dL}

from a baseline of

1.5\text{ mg/dL}

Recognizing active renal and cardiac impairment is crucial for selecting safe medications, as many common drugs rely on renal clearance or alter hemodynamics.

Select the safest first-line pharmacologic agent for the acute flare.

Oral prednisone is selected.

First-line agents for acute gout are NSAIDs, colchicine, and systemic glucocorticoids. Because NSAIDs and colchicine are contraindicated in the setting of acute kidney injury and heart failure, glucocorticoids become the optimal therapy.

Anahtar Kavram

In patients presenting with an acute gout flare who have significant comorbidities such as acute kidney injury or severe heart failure, systemic glucocorticoids are the preferred initial pharmacotherapy due to the absolute contraindications of NSAIDs and colchicine.

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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