Case Scenario:
Patient is an obese male who reports daily ethanol ingestion (obesity, male gender, and ethanol use are risk factors for gout) and was recently started on chlorthalidone for hypertension (HTN) (diuretics and HTN are also risk factors for gout). About 1 month after starting diuretic therapy, the patient develops an acute gouty attack of the right toe after overindulging at Oktoberfest. The patient also presents with acute renal failure secondary to dehydration and diuretic use. His physical exam is classic for acute gouty arthritis including swelling, warmth, and erythema of the affected joint as well as excruciating pain. His pertinent laboratory values reveal a mild leukocytosis and increased erythrocyte sedimentation rate. His serum uric acid (SUA) level is 11.6 mg/dL. His SCr and BUN are elevated. A synovial fluid aspirate of the affected toe joint contains white blood cells and monosodium urate crystals, confirming the diagnosis of gout. Therapeutic alternatives for acute gouty arthritis include NSAIDs, colchicine, and local or systemic corticosteroids. Selection of the most appropriate therapeutic agent primarily depends on length of attack before treatment and comorbidities that may exclude certain treatments. Although NSAIDs are generally preferred because of their low-toxicity profile when used for the short-term treatment of acute gout, this patient's acute renal failure (as well as history of peptic ulcer disease) precludes their use in this patient for the acute gouty attack. Further, in light of the patient's acute renal failure, colchicine should also be avoided as an acute treatment option. Therefore, steroids (either systemic or local) would be the treatment of choice in this patient. Treatment of the patient's HTN is also complicated because of both the acute renal insufficiency and the gouty attack. Once the patient's renal function returns to baseline, losartan would be an ideal antihypertensive in this case, because of its ability to reduce SUA levels as well as control HTN.
QUESTIONS: Answer Questions based on scenario:
Q1. What subjective and objective information indicates the presence of gout?
Q2. Create a list of the patient's drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.
Q3. What are the goals of pharmacotherapy in this case?
Q4. What nondrug therapies for gout might be useful for this patient?
Q5. What feasible pharmacotherapeutic alternatives are available for treating gout?
Q6. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient's gout and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Q7. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
Q8. Describe how care should be coordinated with other healthcare providers.