stitfne Tbee symptoms have boen occurring wth increasng sver

ity lor the past evera wecks. She preented th snikr symptoms 3
momhsago at wch me her drus regimen was changed from
methotreate nd NSAID therpy to her aurrent repimen below.
PMH
RAx6 ears
SP byteTectomyreasa°

**** fTNx 10 years

A
Father died from complbcations ate a traumatic fll at age 6S.
**** Mother died of hip fracture and pneumania
* * *** age 78. No mbling.

Housewife; married for 32 yearz has tro grown children wth no

known medical problems. Dens alcohol or tobacco use. Volun-
**** teers in the community eatensivey, but has been doing les in the
past 2 months.
***** * ****
Meds
iydrochlorothiamide 25 mg po Q AM Norvac
l0 mg po cnce dauy Nabumetone 750 mg, 2
tabs po Q 11S Prednisone 5 mg. "; ab po Q
********** AM Mehotreate 2.5 m 6 tabe po once & week
Hydroaychloroquine 200 mg. I tab po BID
Sulfasalazine EC S00 mg. I tab po BID Folc
cx I mg po once daihY

96 Patient receives medications at a local communsty pharmacy. Mec

ication profile indicates that she refils her medaations on time the
firt od each month.
RHEUMATOID ARTHRITIS DA
Peniilin (rash 25 years ago)
Jont Project..... ROS
.. Level Swellang in ket kner; decresed ROM in hands; marning stifnas
very day for about 3 hours; átigue perienced daiky during
Amy L Whitaker, Phara afterooon hours denes HA, ches pain, SOB, bloeding psodes, o
syncopal ttacki dens nauea vonkng. diarrbea loss at aPpetite or
weight koas; reportı minor viual changes corrected witb stronger
preaiption glaanes.
LEARNING OBJECTIVES Physical
Examinabon
After completng ths case study, the reader shaud be able to: Gen
Recommend ldentty the sgns and symptoms od
Recognze atemabve therapies tor the treatment of pain and
niammabon n pabents with RA.A

theumtod arthnts (RA).

appropnate drug theapy for the management of RA Pleasant,
pain and middle-agrd white wwoman in moderate disres because of
swelling in left knee

Recommend appropnate nonphamacologc optons for man-

BP 138/80, P 82, RR 14, T 37.1C; Wi 65.3 kg. Ht S6"
agng pabents with RAA
skin
Counsel paments abous the drug therapy used to treat RA
No rashesx normal ugor; no breakdown or ucers
PATIENT,PRESENTATION| HEENT
Atraumatic; moon facie; PERRLA; EOMI: AV nicking visible
a Chie Comglint balaterally. pale conjunctiva bilaterally: TMs untact; xerostoma
*I bave pain in all of my joints, a swollen let knee, and niffnens
Meclymph Nodes
vey mommg
Supple, no ND or thyromepaly; no bruits palpable bymph nodes
HM
Che
anet liobbs is a S8 year-old woman who presents to her rheumatod
opst with generaized arthralps, a swolen A kne, and morning CTA
LTABLE 96-1
Na 135 mEol Hab100 8d4 AST 15 CK 20 A kospng pd roer
K41 mECn ALT 12 RL ANA ner T. dhd 219 ng
d 101 mto Wec 130 x 10'/mm Aphas 56 U Wes E 47 mmyh LR 106 mpol
Co 22 mEql PR 56 x 10/m blh 08 mgdl RF (-) 1.1280 HDL S0 mg
BUN 12 mgd Ca 1 mg Ab 42 pa Ar-CCP ( TG 150 mp
SC a8 mgd Urte S.1 mp HbsAg(-)
Cku 10G mdl TSH a74 mlL A+CY (-) R 1D

is contraed on preent therapy. DEXA can reubs suggestive of

Norma; no lunps osteopena

RRR: normal Si. Si no MRG

QUESTIONS|
Abd Problem Identification
Sot, NTND; (+) BS 1.4. list the petient's drug therapy problems
Cenyed Deferred .b.What inkormation (igns, synptoms laboratory ahues) indi
cates the preace and severiy of rheumatoid arthritis?
l.c. What additional information is needed to asexs the patient?
Hand: aidd RA changes swelling of the 3rd, 4th, and Sth P1P joints Desired Outcome
bilaterally pain in the 3rd and 4th MCP joints on ieft; bouton.
nire deformity of the 3rd and h digits bilaterally; ulnr 2. What are the goals of pharmacotherapy in this ca
deviation baateraly: decreased gp strength L> R (patient is Therapeutic Aternatives
et-handed

Wrists: decremed ROM

Ebowr good ROM: sipht permanent coatmcture on night fzed 3.a. What nonpharmacologic modalities may be benefici for this
odhale at pressure point patieot?
Shoulders decreused ROM (especially abduction) bilaterally 3.b What pharmacolopic aternatives are available o the treat
Hips: decreased ROM on rnght; atropby of quadriceps, L >R ment o RA?
Knees: pain bilaterally, decreased ROM on left; efkusion/edeme n 3.c. What economic and paychosocial considerations are applicable
left to this petient?

Feet no odemas; hull plantar Blecioa and dorilaion; 3+ pedal pulsa Optimal Plan
Neur 4. What dn, dasage fom, dose, achbedule, and duration of therapy are
CN1-XII grossly intact muade trength 5/5 UE, V5 LE DTRs 2/4
bet for this patient
biceps and tricep, 1/4 patela
Outcome Evauation
Labs
5. What clinical and Laboratory parameters are necesary to evaluate the
See Table 96.1 patient's drug therapy
A
Patient Education
Normal
6. What intormation shouk be provided to the patient to ahance
a Che ay adherenoE, ure suocesshul thernpy. and minimire advere
No Ouid, musa, or inbection; no cardiomega eflect
Hand -ay SELF-STUDY ASSIGNMENTS
Erosion of MCP and PIP joints bilaterally; meusurable joint space 1. Performs kterature arch and awen the risk of cardiovascular
narrowing from previous 3 ray 6 months ago a Syaovial Fuid events aociated with NSAID us
From let kne; white cels 23.0 x 10hmn', turbid in appearance 2. Cremea kst od the cdinically sigaificant drug interactions Sor
NSAID and DMARDs incduding methotraate.
a DEA San of hip/spine T-care neported as -2 D Assexment 3. Compare the biotogic agents used to treat rheunatoid arthritis
S8-year-old woman in moderate distres with acute dare of RA with respeoct to cass of agent, route of administration, eflicacy. and
incidence of side effects.
(functional class 11). RA not adequatety cortroled with curent
therpy. Patient is adhereat with current medication repimea HTN
CLINICAL PEARLT

Treat wih high-dose corticosteroids to obtain short-term benefit

and rebeve the fare of rheumatoid arthrtis. Concurrenthy. ar

=
 LEARNING OBJECTIVES
After completng ths case sucy, the reader shoud be able to:
Recognze maor nsk tactors for developng gout in a gven pa-bert,
incudng drugs that may ontrbute to r cause ths dis-order.

Develop a phamacotherapeutic plan for a patet wth aaute gouty

arthnts that uncludes indvdualzed drug selechon and3
assessment of the treatment for efficacy or tooat
ldentty paterts in whom mantenance therapy for gout and
hypenuncema s wamanted.
Select medcatons that treat hyperternson or dyshpedema that
may have a benehoal eftect on serum unc aad leveln pa berts
wrth gout

PATIENT PRESENTATION

a Chief Complaint
"t can't walk because my ankle is killing me"
HP
Nathan Vance is a 66- year old man with a history of dylapademis
who presents to the emergency department of his kocal hospital. Ite is
suffenng from sudden anset of ercruciutung pain in his leh ankle that
woke hum up a 5:00 AM this morning. Over the lst 2 hours, bis let
anke has become red and swollen, and the pan frocn the joint is so
**** bad that he cannot walk Ne relates no trauma or injury to the ankle
** ****R and has nat exerted himself more than usual in the recent past. He
also denies baving erperienced thee symptoms previously.
PMH
Dyslipidemis, peptic uker disease (duodenal uoer discovered 6
Cmonths ago), and obesity

The patient drinks "a can of beer or hwo" daiy. He does noi smoke
**** ***t or use illit drugs.
*** *

Meds
Extended-release niacin (Niaspan) 1,000 mg po at bedtume, started 2

98 months Ago

Omeprazole 20 mg po daily

GOUT AND HYPERURICEMIA Seavastatin and atorvastatin (both caused severe musce aches, and the

The Disease of Kings... patient was foned to discontinue them)

. . Level II ROS

Ceodirey C al, Pharmd, BOs cC The paticnt has no mapor complaints prior to this mergency room
visit. He relates feeling "hot and fhushed" occasionally after taking
his niacin, but this hs not beena major problem for him. No hes
pain, nauscavomitmg or respiratory symptoms. Bowel habets are
ormal. 1le has no prior bistory of arthntic symptoms or joint
problems.

a Physical Examinsion
Gen
A bealthy ppearing, obese, white male in acute distres
PERRLA, throat/ears dear of rednes or inflammation
BP 135/88, P 100, RR 18, T 37.5 C W 97 kg. H S11"
Medtylyanph uodes
Stin
Negative for lymph node swelling or maes
No rashes or other dermatologic abnormalities Has aul tattoo on
Lungy/Thor
his leh arm.
Clear to ausculution bilateraly, symmetric mavement with inspira
HCENT tion
 1b. What patient inforrmation {symptoms, nigns, kboratoy values)
CV
indicates the prenence or severity of acute gouty arthritis?
RRR, normal 5, and S 1c. What nedication is the patient taking that could contribute to
or canse gouty arthriti
Obee, but soft, nontender. Positive bowel sounds in all quadrants. Desired Outcome
Ceniect 2. What are the goals of pharmacotbeapy in thas case?
Delerred
Therapeutic Alternatives
3a What nondrug therapies may be useul for this patient?
3.b. What pharmacotherapeutic modalities are available for the
treatnent of acute gouty arthrits?
3.c. Sboud chroaic treastment to decreae the patient's serum uric
acid level be inatiated ar this time? Wby or why not?

Optimal Plan
4a Conmdering the patient's informtbon, what drug, domge
form, chedule, and duration of therapy are best in this cae?
4.b. What gent would be best to treat the patient's hyperlipademia?

Outcome Evaluation
5. Which cdanical and laboratory perameters hould be monitored to
assess the eéicacy of the pharmacotherapeutic plan and to pre
vent adverse effects?
Let ankle with 3+ edema around joinm, contrasted eryehema
present, and very warm to touch. Joint is exquisitey painkal with Patient Education
patient relating the pain as currenthy a 10/10 (on a 1-10 cak with 6. What inkormatson sboud be provided to the patiend to enhance
1 beng no pain and "10* being ihe ware pain the patiem has ever
dherence, cneure succeshul therpy. and to avoid advere ettoct
suffered). No swelking of any other jeints incduding great toe. No
igns of tophi present. LINICAL COURSE

Meuro The patient responded to the therapr you recmmmended and within
% hours his pain has subided significantly. Ande redness and swelling
A &0x3.CNI-XIl grosely intact, no focal neurologic deficits
have decreased to noar normal. After consutabon with you, the
patienM's phyican decides against mantenance therapy to decrease
serum unc acid kves Tbe patient, remerabering the ver pain this
wu 12 x 10''m ipdpaw Uh
episode caused folows your recommended lifestyle changes and a
K9mEA Neuns adihcrent to the new medicboa you reocommend tor has dylipidemia
2 m'L 2t9 1m LDiCPmgdL At his 6- month follow-up appointment, he reports no more atacks of
gout. IHe hes loet 20 lb and no longer drinks ethanol His serun urnc
BUN9 MLV l T. chal 1 pdL acid level has decreaaed to 69 mg/dL and a fating lipid profile
Momoa 1 demonstrates a trigyceride lrvel of 168 mgdL and FDL-Cof 41 mgd
RF

iive

Andtle radiograph: negatve for break or damage

Aspirated fuid from anke joint tap: >50 WBC/HPF, containing
negatrvely birchrangent monosodium urate crystals
Asessmeent
1. Primary presentation of acute gouty arthritis
2. Type V dylipidernia uncontralled on medical therapy
3. Probable advere drug eaction: drug imduced gout
4.History of duodenal ukoer on maintenance antisecretory therapr

QUESTIONS
****
Problem ldentification
aCreatea ist of the patiesn's drug therapy problems.