A 65-year-old man comes to the physician due to attacks of joint pain and swelling that affect primarily his hands but sometimes his knees or elbows. He currently has no pain, but the episodes occur once or twice a month.
The patient's other medical problems include type 2 diabetes mellitus and hypertension. He has not seen a physician for 2 years, and he has managed his diabetes with diet. He was diagnosed with arthritis 2 years ago at a different clinic and was prescribed ibuprofen. The patient smokes 1-2 packs of cigarettes a day and drinks 2-3 cans of beer each night.
Temperature is 36.7 C (98 F) , blood pressure is 155/96 mm Hg, pulse is 84/min, and respirations are 16/min. The patient's BMI is 35 kg/m². He has clear lungs and normal first and second heart sounds. His abdomen is obese, nontender, and without hepatosplenomegaly. His fingers are shown in the images below. There is no joint tenderness and no joint effusions are present elsewhere.

Serum creatinine level is normal and fasting blood glucose level is 133 mg/dL.
Which of the following agents is most likely to provide long-term relief for this patient's symptoms?

Question

A 65-year-old man comes to the physician due to attacks of joint pain and swelling that affect primarily his hands but sometimes his knees or elbows. He currently has no pain, but the episodes occur once or twice a month.
The patient's other medical problems include type 2 diabetes mellitus and hypertension. He has not seen a physician for 2 years, and he has managed his diabetes with diet. He was diagnosed with arthritis 2 years ago at a different clinic and was prescribed ibuprofen. The patient smokes 1-2 packs of cigarettes a day and drinks 2-3 cans of beer each night.
Temperature is 36.7 C (98 F) , blood pressure is 155/96 mm Hg, pulse is 84/min, and respirations are 16/min. The patient's BMI is 35 kg/m². He has clear lungs and normal first and second heart sounds. His abdomen is obese, nontender, and without hepatosplenomegaly. His fingers are shown in the images below. There is no joint tenderness and no joint effusions are present elsewhere.

Serum creatinine level is normal and fasting blood glucose level is 133 mg/dL.
Which of the following agents is most likely to provide long-term relief for this patient's symptoms?

Quizplus · Accepted Answer

This patient with metabolic syndrome (which increases the risk of developing hyperuricemia) has visible tophi over the distal interphalangeal (DIP) joints of the index fingers and thumbs. Tophaceous gout indicates chronic intraarticular uric acid crystal deposition and can present in multiple joints and in the ears. Patients typically have nontender nodules and joint destruction mimicking other inflammatory conditions such as rheumatoid arthritis (RA) (although RA would have different clinical manifestations and would spare the DIP joints, unlike in this patient). The diagnosis of tophaceous gout is made clinically, sometimes with the help of radiographs showing bony erosions. Urate crystals can generally be seen on aspiration of previously affected joints. Serum uric acid levels can be normal in extensive tophaceous gout and should not be used to confirm the diagnosis. clinical manifestations For patients with frequent attacks of gouty arthritis, allopurinol (a xanthine oxidase inhibitor) with a target uric acid level of <6 mg/dL is indicated to reduce tophi burden and joint destruction; a target level of <5 mg/dL may lead to faster resolution of the tophi. A short course of gout flare prophylaxis (eg, colchicine) should be administered when anti-hyperuricemic therapy is initiated. Febuxostat, another xanthine oxidase inhibitor, is an alternate agent for patients who cannot tolerate allopurinol or who do not reach the target uric acid level; it is more expensive, and monitoring of liver function tests is recommended with therapy. (Choice B) Etanercept is a tumor necrosis factor inhibitor indicated for severe RA, psoriatic arthritis, ankylosing spondylitis, and chronic plaque psoriasis. (Choices C and E) Methotrexate and sulfasalazine are disease-modifying anti-rheumatic drugs (DMARDs) used to treat RA. (Choice D) Prednisone is used in the treatment of acute polyarticular attacks of gout in patients who cannot tolerate, or have contraindications to, nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine. Glucocorticoids can be used in the initial management of severely active RA, often in combination with NSAIDs and while DMARD therapy is initiated. Educational objective: Recurrent polyarticular gout can lead to tophaceous gout. Allopurinol is the preferred treatment. __________ References: Prevalence of insulin resistance and metabolic syndrome in patients with gouty arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/20091036) Misdiagnosis of rheumatoid arthritis in an elderly woman with gout. (http://www.ncbi.nlm.nih.gov/pubmed/2010592) Treatment of hyperuricaemia and gout. (http://www.ncbi.nlm.nih.gov/pubmed/23908515)

A 65-Year-Old Man Comes to the Physician Due to Attacks