Gout

1. Which of the following is the most common cause of gout?
a. Intake of purine-rich foods
b. Decreased tubular secretion of uric acid
c. Alcohol consumption
d. Medications

2. Which medication is the BEST to use for a patient with gout and hypertension because it promotes uric acid secretion?
a. Lisinopril
b. Atenolol
c. Losartan
d. Hydrochlorothiazide

3. Why is Naproxen a poor choice in the treatment of gout in a patient with CKD?
a. It constricts the afferent arterioles
b. It dilates the afferent arterioles
c. You are not allowed to use NSAIDS in the treatment of gout
d. You can use any NSAID in a patient with CKD and gout

4. Which medication treats gout by increasing the plasma pH?
a. Colchicine
b. Allopurinol
c. Pegloticase
d. Probenecid

5. Hyperuricemia is elevated uric acid levels in serum that is _________.
a. >6 mg/dL
b. <6 mg/dL
c. >6.8 mg/dL
d. <6.8 mg/dL

6. Which of the following statements about the epidemiology of gout is FALSE?
a. Gout affects men approximately 4 times more than women at a younger age.
b. Estrogen stimulates the renal excretion of uric acid.
c. Not all patients who have hyperuricemia have gout.
d. Underexcretion of uric acid accounts for approximately 10% of cases.

7. True or false: Purines are the main source of uric acid in the formation of gout.
a. True
b. False

8. Purines originate from the following sources EXCEPT:
a. Dietary purine
b. A de novo pathway in which purines are synthesized from non-purine precursors
c. A salvage pathway in which free purine bases are captured from the breakdown of nucleic acids of endogenous or exogenous origin
d. All of the above are examples of how purines originate

9. Which of the following statement(s) is TRUE regarding hyperuricemia? (select all that apply)
a. Increased activity of PRPP synthetase leads to an increase in PRPP which is a key component of purine synthesis.
b. Decreased activity of HGPRT results in reduced metabolism of guanine and hypoxanthine to guanylic acid, adenylic acid, and inosinic acid.
c. Increased activity of HGPRT results in reduced metabolism of guanine and hypoxanthine to guanylic acid, adenylic acid, and inosinic acid.
d. Decreased activity of PRPP synthetase leads to an increase in PRPP which is a key component of purine synthesis

10. Which of the following statements is FALSE about Probenecid?
a. The initial dose is 250 mg po BID for 1-2 weeks
b. It has a possible interaction with low-dose aspirin
c. It is contraindicated in patients with nephrolithiasis
d. There are no renal dosing adjustments for this medication **(it is contraindicated below 30 ml/min and not recommended as first line monotherapy under 50 ml/min)
e. It inhibits the URAT1, decreasing the reabsorption of uric acid in the proximal tubules.

11. Why is an increase in plasma pH with Colcrys beneficial in the treatment of gout? (select all that apply)
a. It decreases urate solubility
b. It deprotonates uric acid
c. Less ionization occurs at a higher pH
d. it inhibits the production of lactic acid
e. It protonates uric acid

12. Which of the following medications is NOT used as monotherapy?
a. Lesinurad
b. Allopurinol
c. Febuxostat
d. Probenecid

13. What are the major excreted product(s) of purine metabolism? (select all that apply)
a. Guanine
b. Oxypurinol
c. Xanthine
d. Hypoxanthine

14. Put the four stages of gout in order from first to last:
a. Acute gouty arthritis 1._________
b. Chronic tophaceous gout a
2.________
c. Asymptomatic hyperuricemia 3._________
d. Intercritical gout
4.________

15. Which of the following statements is FALSE?
a. Approximately two-thirds of uric acid is excreted from the body in the urine.
b. About one-third of uric acid is eliminated through secretion into the GI tract followed by enzymatic degradation by colonic bacteria and excretion in feces.
c. Filtered uric acid is mostly reabsorbed in the proximal convoluted tubule.
d. An individual that excretes more than 600 mg of uric acid per 24 hours on a purine-free diet is considered an underexcretor.

16. An acute attack of gout of the big toe is referred to as:
a. Impetigo
b. Podagra
c. Tophi
d. Pannus

17. True or false: Patients with high levels of uric acid are always classified as having gout.
a. True
b. False

18. Crystal-induced inflammation results in all of the following EXCEPT:
a. Vasodilation
b. Decreased vascular permeability
c. Additional complement activation
d. Edematous synovium

19. __________ occur(s) in 10-25% of patients with gout.
a. Kidney stones
b. Hypertension
c. Cellulitis
d. Type II DM

20. Which of the following is the most accurate mechanism of action of Lesinurad?
a. Reversibly inhibits the enzyme xanthine oxidase and ultimately inhibits uric acid synthesis.
b. Stimulates lipocortin synthesis ultimately resulting in lower production of inflammatory prostaglandins.
c. Inhibits only URAT1, decreasing the reabsorption of uric acid in the proximal tubules.
d. Inhibits URAT1, which is responsible for the majority of the reabsorption of filtered uric acid from the renal tubular lumen and OAT4, a protein associated with diuretic-induced hyperuricemia.
e. Converts uric acid to the water soluble molecule allantoin, which is an inactive metabolite of uric acid.

21. JB is presenting to the ED with an acute gout attack. His medications include: Lisinopril, Furosemide, Ibuprofen, and Atorvastatin. Which medication is MOST likely responsible for his acute gout attack?
a. Lisinopril
b. Furosemide (CANT LEAP)
c. Ibuprofen
d. Atorvastatin

22. When JB presented to the ED in the previous question, it was 12 hours after his acute gout attack started. Which medication is most appropriate to administer?
a. Allopurinol
b. Febuxostat
c. Colchicine
d. Probenecid

23. The most important counseling point for a patient taking allopurinol is:
a. You may get diarrhea and GI discomfort after taking this medication.
b. You should stop taking the medication and call your doctor immediately if a rash develops.
c. You may get extremely tired or dizzy when taking this medication. This is normal.
d. If you end up with acute renal failure from this medication.

24. In general, preventative treatment for gout should be initiated in patients with:
a. Manifestations of tophi
b. Two or more gout attacks per year
c. Nephrolithiasis
d. All of the above

25. Which medication is recommended as first-line pharmacologic urate-lowering therapy for gout?
a. Probenecid
b. Allopurinol
c. Colchicine
d. Lesinurad

26. What does Pegloticase have a BBW for?
a. Anaphylactic/infusion reactions
b. Agranulocytosis
c. Stevens-Johnson syndrome
d. Acute liver failure

27. Which of the following statements is FALSE?
a. The current approved dosing for colchicine is 1.2 mg PO at the first sign of a gout attack and 0.6 mg PO one hour later.
b. Colchicine at 0.6 mg PO daily or 0.6 mg PO bid or an NSAID should be administered concurrently with the xanthine oxidase inhibitor or uricosurics agents during the first 6 to 12 months of uric acid-lowering therapy to minimize the risk of an acute attack.
c. Although colchicine is effective, 80% of patients experience significant GI side effects (nausea, vomiting, diarrhea, abdominal cramping) at standard doses before relief of the attack. Diarrhea is usually the limiting side effect.
d. All of the above are true statements

28. Adenine nucleotides are degraded to _________ while guanine nucleotides are metabolized to guanine. Both are then converted to ________, which is oxidized by xanthine oxidoreductase to uric acid.
a. Adenine; guanine; hypoxanthine
b. Hypoxanthine; guanine; hypoxanthine
c. Adenine; guanine; xanthine
d. Hypoxanthine; guanine; xanthine