Disease of Kings
A 59-year-old woman with systemic lupus erythematosus (SLE) is seen in one of your rheumatology clinic’s urgent afternoon slots regarding pain and swelling in her bilateral ankles, knees, and wrists since the morning. In addition to SLE, her past medical history includes crystal-proven gout, hypertension, type 2 diabetes mellitus, and obesity. She has about 1 gout flare per year, most recently 6 months ago, for which she has previously used colchicine with good effect. Her SLE has been complicated in the last 3 months by new onset biopsy-proven nephritis. Current medications include voclosporin 23.7 mg twice daily, mycophenolate mofetil 1 g twice daily, allopurinol 300 mg daily, insulin glargine 15 units daily, lisinopril 10 mg daily, and metformin 500 mg twice daily. On physical examination, she is afebrile, heart rate 94, blood pressure 128/78, body mass index 31kg/m2. There is bilateral swelling and tenderness of the ankles, knees, and wrists. Arthrocentesis of her knee reveals 12,000 leukocytes/μL and intracellular needle-shaped negatively birefringent crystals. Gram stain is negative. Laboratory tests include: ALT 21, AST 18, BUN 20, Creatinine 1.1, CRP 2.4, ESR 32, Hgb A1c 9.8%, WBC 5700, Uric acid 8.2.
Which of the following is the most appropriate dose of colchicine to take today for her current condition? 0.3mg, 0.6mg, 0.6mg and then 0.3mg 1 hour later, 1.2mg and then 0.6mg 1 hour later
0.3mg x 1, then no further colchicine for 3-7 days to avoid colchicine toxicity in setting of voclosporin use
A 65-year-old woman with a history of type 2 diabetes and hypertension presents to your office due to concerns about possible gout. She has no current foot or ankle pain or swelling but complains of intermittent sharp pain at the base of both great toes, which is worse with pressure or ambulation for longer than 15 minutes. She denies other joint complaints. She denies history of kidney stones or tophi. She does not smoke cigarettes or drink alcohol. She notes a family history of gout in her father and older brother.Current medications include metformin 500 mg twice daily, dapaglifozin 10 mg daily, candesartan 16mg daily, calcium 500 mg twice daily, vitamin C 250 mg daily, aspirin 81 mg daily, and acetaminophen 325 mg twice daily as needed for joint pain.On physical examination, she has bilateral hallux valgus without synovitis. She has mild tenderness with palpation and range of motion at the first metatarsophalangeal joint bilaterally. There is no synovitis of the ankles or knees and no evidence of olecranon bursitis. There are no tophi. She was recently seen by her primary care provider, and laboratory tests revealed a uric acid level of7.2 mg/dL (reference range, 3.0-7.0 mg/dL) with a serum creatinine of 1.1 mg/dL (reference range,0.5-1.1 mg/dL).Which of the patient’s current medications is most likely to reduce her risk of developing gout? Aspirin, Candesartan, Dapagliflozin, or Vitamin D
Dapagliflozin
A 57-year-old woman presents to rheumatology clinic with a 1-week history of pain and swelling of hright first metatarsophalangeal (MTP) joint and right knee. She recalls having a similar episode a yearago resolved with ibuprofen. Her history is notable for diet-controlled type 2 diabetes and obesity. Heronly medication is ibuprofen as needed. Her family history is notable for a father who developed goutin his 50s. She does not use tobacco or alcohol. She works as a biochemist at the local university.On physical examination, vital signs are within normal limits except for abody mass index of 32 kg/m2.She is a well-appearing woman in no acute distress. Cardiopulmonary examination is unremarkable.Neurologic examination is normal. On joint examination, there is erythema, swelling, and warmthinvolving the right first MTP joint and a large right knee effusion.Knee effusion aspiration reveals 14,000 leukocytes/μL and intracellular negatively birefringent needle-shaped crystals.Laboratory tests show: ESR 40, CRP 5, Serum Creatinine 0.9, Uric acid 10.2.
You counsel her regarding the diagnosis, offer ibuprofen for treatment, and recommend follow up in a month. She inquires if there is any research into the underlying cause of her symptoms.Which of the following genes is the most likely to be involved in the pathogenesis of her underlying condition? ATP binding cassette subfamily G member 2(ABCG2); Progressive ankylosis protein homolog (ANKH); Hypoxanthine-guanine phosphoribosyltransferase (HGPRT); Phosphoribosylpyrophosphate synthetase (PRPS)
ATP binding cassette subfamily G member 2(ABCG2)