Examkin

Soru

Zorluk: OrtaPharmacologic Interventions

A 65-year-old man presents to the clinic with severe pain, swelling, and redness in his right knee that began 24 hours ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, chronic kidney disease stage 4 with a baseline estimated glomerular filtration rate of 22 mL/min/1.73 m², and a prior episode of upper gastrointestinal bleeding secondary to a peptic ulcer. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 110/70 mmHg, and heart rate of 82/min. Physical examination reveals a warm, erythematous, and markedly tender right knee with a moderate effusion. Arthrocentesis is performed, and synovial fluid analysis reveals a leukocyte count of 28,000/mm³ and the presence of negatively birefringent, needle-shaped crystals under polarizing microscopy. Gram stain reveals no organisms. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute symptoms?

  1. Intra-articular triamcinoloneCevap
  2. B
    Oral indomethacin
  3. C
    Oral colchicine
  4. D
    Oral allopurinol
  5. E
    Intravenous vancomycin

Cevap

The correct answer is intra-articular triamcinolone.
The patient is experiencing an acute gout flare, evidenced by sudden-onset monoarticular pain, swelling, and synovial fluid containing negatively birefringent, needle-shaped crystals. Standard first-line treatments for acute gout include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and systemic or intra-articular glucocorticoids. When selecting a therapy, the patient's comorbidities must be heavily considered. This patient has advanced chronic kidney disease (eGFR 22 mL/min/1.73 m²), heart failure with reduced ejection fraction, and a history of peptic ulcer disease. NSAIDs are absolutely contraindicated due to the high risk of exacerbating his renal failure, promoting fluid retention that could decompensate his heart failure, and causing recurrent gastrointestinal bleeding. Colchicine is cleared by the kidneys and requires extreme caution or strict avoidance in severe renal impairment due to the risk of life-threatening bone marrow suppression and neuromyopathy. While systemic glucocorticoids could be used, they carry a risk of fluid retention. Because the patient has monoarticular involvement, an intra-articular glucocorticoid injection (such as triamcinolone) provides targeted, highly effective anti-inflammatory action with minimal systemic absorption, making it the safest initial pharmacologic intervention.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and synovial fluid results.
The presence of negatively birefringent, needle-shaped crystals and a sterile inflammatory synovial fluid confirms an acute gout flare.
Establishing the correct diagnosis is prerequisite to selecting the appropriate targeted pharmacologic therapy.
2
Evaluate the patient's medical history for contraindications to standard gout therapies.
The patient has advanced chronic kidney disease (CKD stage 4), heart failure with reduced ejection fraction, and a history of peptic ulcer disease.
First-line systemic therapies for gout (NSAIDs, colchicine) have significant toxicities that must be weighed against patient comorbidities.
3
Select the safest and most effective targeted intervention for monoarticular gout.
Intra-articular triamcinolone is chosen over systemic agents.
NSAIDs and colchicine are contraindicated or highly risky due to his medical history. A local intra-articular corticosteroid injection provides excellent relief with minimal systemic side effects.

Anahtar Kavram

Selecting the appropriate acute treatment for gout flares by identifying absolute and relative contraindications to NSAIDs and colchicine based on patient comorbidities.
Bu soruyu puanla

Konular

Pharmacologic Interventions

Bu konudan daha fazla soru