Pharm Arthritis And Gout Part 2

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  • 1/20 Questions

    A 49-year-old alcoholic woman, brought to the emergency room by her husband, was disoriented, combative and complained of headache, vertigo, and “ringing in my ears.”. The husband referred that she recently said she wanted to commit suicide. Vital sings were: temperature 104 F°, pulse 108 bpm, respirations 6/min, blood pressure 85/60. Pertinent lab data on admission were: arterial blood pH 7.25, creatinine 2.2, bicarbonate 18 mEq/L, glucose 170 mg/dL. Arterial blood gases on room air were: Pa CO2 48 mm Hg (normal 35- 45), Pa O2 70 mm Hg (normal 75-100). Which of the following drugs most likely caused this poisoning?

    • Ethanol
    • Celecoxib
    • Ketorolac
    • Ibuprofen
    • Aspirin
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About This Quiz

Welcome back to our two-part series on the topics of arthritis and its sub-category of gout. You may have faired well in the first chapter of this quiz, but do you know enough about the pharmacology of these disorders to get all these questions right? Let’s find out now!

Pharm Arthritis And Gout Part 2 - Quiz

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  • 2. 

    A 55-year-old man suffering from gouty arthritis and hyperuricemia has been receiving allopurinol for one month. Now he presents with a maculopapular rash and the physician decides to discontinue the allopurinol and to start a treatment with probenecid. The physician should advice the patient not to use concurrently which of the following drugs?

    • Acetaminophen

    • Ibuprofen

    • Celecoxib

    • Aspirin

    • Piroxicam

    Correct Answer
    A. Aspirin
    Explanation
    In man uric acid is filtered by the glomerulus and 98% is reabsorbed in the proximal tubule by a
    brush border transporter. The remaining 2% makes up about 20% of the uric acid eliminated by
    the kidney. The remaining comes from tubular secretion by an active transport system that
    eliminates organic acid. Uricosuric drugs like probenecid and salicylates compete with uric acid
    for these transport mechanisms. They have a paradoxical effect because, depending on
    dosage, they may either decrease or increase the elimination of uric acid. It seems that the
    secretory mechanism is more sensitive to the blocking action of uricosuric drugs, so low doses
    can block uric acid secretion only. Higher doses are able to block both mechanisms and
    therefore, since most of the uric acid is reabsorbed, the net results is an increased elimination.
    Salicylates like aspirin can completely antagonize the uricosuric action of probenecid. This
    interaction probably involves several mechanisms including competition for renal tubular
    transport.
    A, B, C, E) (see explanation above)

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  • 3. 

    An 18-year-old male presents to the emergency room with persistent nausea and vomiting, malaise and diaphoresis. He has been overtreating himself for four days with an analgesic medication to relieve severe discomfort from a neck injury. Two days earlier he got drunk at a party. Physical exam shows a slightly confused and dehydrated patient with icterus and a flapping tremor. Lab exams reveal extremely high serum transaminase levels. The patient has most likely taken an excessive dose of which of the following drugs?

    • Aspirin

    • Indomethacin

    • Acetaminophen

    • Ibuprofen

    • Ketorolac

    Correct Answer
    A. Acetaminophen
    Explanation
    Poisoning from acetaminophen is due to toxic metabolites (mainly N-acetyl parabenzoquinone)
    that accumulate when glutathione is not available for conjugation. In the
    absence of glutathione these toxic metabolites react with cellular proteins, resulting in
    hepatotoxicity. This occurs after the ingestion of toxic doses or when alcohol is taken together
    with acetaminophen, since in both cases glutathione is depleted faster than it can be
    generated.
    The alcohol-acetaminophen syndrome occurs in a clinical setting in which acute, sometimes
    fulminant, hepatic necrosis develops after large doses of acetaminophen are taken during an
    alcoholic binge or a period of chronic, excessive alcohol intake. Peculiar to the alcoholacetaminophen
    syndrome are the extremely high serum transaminase levels. Early treatment
    consists of the administration of N-acetylcysteine, although at 48 hours or more after the
    ingestion its use remains controversial.
    A, B, D, E) Overdose of all the other listed drugs does not cause a high increase in serum
    transaminase levels.

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  • 4. 

    A 62-year-old male suffering from osteoarthritis presented to the emergency room with nausea, headache, dizziness, tinnitus, difficulty in hearing and sweating. His body temperature was 104F. He had been overtreating himself for four days with aspirin in an attempt to relieve a severe pain from his right hip. Which of the following statements best explains the reason of hyperthermia in this patient?

    • Increased uric acid reabsorption by the kidney

    • Decreased water and Na+ reabsorption by the kidney

    • Increased platelet aggregation

    • Uncoupling of oxidative phosphorylation in skeletal muscle

    • Metabolic alkalosis

    Correct Answer
    A. Uncoupling of oxidative phosphorylation in skeletal muscle
    Explanation
    The signs and symptoms of the patient indicate that he is suffering from salicylate overdose toxicity.
    Even if salicylates have an antipyretic action they can cause hyperthermia when given in too high doses. --This seems mainly due to the uncoupling of oxidative phosphorylation in skeletal muscle, that is oxidation proceeds without phosphorylation so producing heat.
    This action is quite similar to that produced by dinitrophenol.
    A, B, C, E) All these are actions of salicylates but have nothing to do with salicylate induced
    hyperthermia.

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  • 5. 

    A 55-year-old woman with a long history of osteoarthritis presented to the emergency room because of a severe colicky pain in the right lumbar region. The history of the patient was significant for episodes of severe arthritic pain, for which she was taking several types of pain killers, for hypertension presently treated with hydrochlorothiazide and captopril, and from hypothyroidism presently treated with thyroxine. A renal biopsy confirmed the diagnosis of papillary necrosis and tubulo-interstitial inflammation of the kidney. Which of the following events most likely caused the patient’s disease?

    • Diuretic induced hypokalemia

    • Captopril induced increase of bradykinin

    • Chronic use of analgesic combinations

    • Captopril induced hyperkalemia

    • Diuretic induced dehydration

    • Excessive dosage of thyroxine

    Correct Answer
    A. Chronic use of analgesic combinations
    Explanation
    Chronic use (6-8 months, or more) of antipyretic analgesics can cause a nephropathy which is
    characterized by renal papillary necrosis (the primary lesion) and chronic interstitial nephritis.
    The cause of the disease is still uncertain but it seems related to the chronic inhibition of
    prostaglandin biosynthesis. The risk increases with the use of analgesic combinations, like in
    the present case.
    A, B, D, E, F) (see explanation above)

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  • 6. 

    A 55-year-old woman complained of blurred vision, night blindness, light flashes and photophobia. The woman, diagnosed with rheumatoid arthritis six months ago, started a therapy with aspirin, but her disease continued to progress and two months ago the physician decided to add a second drug to the therapeutic regimen. Which of the following drugs most likely caused the symptoms reported by the patient?

    • Ibuprofen

    • Aspirin

    • Acetaminophen

    • Hydroxychloroquine

    • Auranofin

    • Celecoxib

    Correct Answer
    A. Hydroxychloroquine
    Explanation
    NSAIDs offer mainly a symptomatic relief in rheumatoid arthritis, but have little effect on the
    progression of bone and cartilage destruction. Drugs that may slow this progression (by
    reducing joint inflammation and preventing joint damage) are called disease-modifying
    antirheumatic drugs (DMARDS) and include some antimalarial drugs (chloroquine and
    hydroxychloroquine), gold compounds, sulfasalazine, and several immunosuppressant drugs
    (including glucocorticoids). These drugs are slow acting antiinflammatory agents and the effect
    may take 2-6 months to become apparent. Their mechanism of action is still uncertain, but they
    are often useful as adjuncts to treatment with NSAIDs. The symptoms of the patient indicate an
    initial retinopathy, a rare adverse effect of several antimalarial drugs after long term treatment.
    A, B, C, E, F) All these drugs can be used in rheumatoid arthritis but they do not cause retinal
    damage.

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  • 7. 

    A 7-year-old boy with influenza received an antipyretic drug for 4 days. On the fifth day he lapsed into coma and died. The autopsy disclosed a diffuse microvescicular fatty infiltration of liver, heart, and kidney, and a cerebral edema. Which of the following antipyretics was most likely administered?

    • Acetaminophen

    • Piroxicam

    • Ibuprofen

    • Aspirin

    • Ketorolac

    • Indomethacin

    Correct Answer
    A. Aspirin
    Explanation
    The results of the autopsy and the history of the patient suggest that the cause of death was Reye’s syndrome. The syndrome consists of an acute encephalopathy with fatty degeneration of the viscera. It is usually seen in children and lethality is estimated to be about 20 %.
    The cause of the syndrome is unknown, but risk factors involve viral infection and use of salicylates, like in the present case.
    The prevalence of Reye’s the syndrome is very low (about 1:100000) but the use of salicylates during a viral illness increases risk for developing the syndrome by as much as 35 fold.
    A, B, C, E, F) These drugs do not cause the Reye’s syndrome.

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  • 8. 

    A 55-year-old man complained of fatigue and shortness of breath, and looked pale and tired. The man, who was vegetarian, also noted that his stools recently had become dark. He has been receiving aspirin for six months to treat his rheumatoid arthritis. Which of the following pathologic states most likely caused the patient’s symptoms?

    • Iron deficiency anemia

    • Respiratory alkalosis

    • Reye's syndrome

    • Analgesic nephropathy

    • Aspirin hypersensitivity

    Correct Answer
    A. Iron deficiency anemia
    Explanation
    The symptoms and the history of the patient suggest that he is affected by iron deficiency
    anemia. In adult males the most common causes of iron deficiency anemias is chronic occult
    bleeding, which is present in more than 70 % of patients chronically treated with salicylates.
    Iron deficiency from inadequate diet can also contribute to the anemia, like in the present case
    (the man was vegetarian).
    B, C, D, E) (see explanation above)

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  • 9. 

    A 14-year-old girl is seen in the primary care clinic because of severe abdominal pain secondary to her menstrual periods. The pain begins with the onset of her menstrual flow and has occurred monthly for the past 5 months. She states that her first menstrual period was at age 13. Her physical examination was within normal limits. A diagnosis of primary dysmenorrhea is made. Which of the following drugs would be most appropriate for this patient?

    • Acetaminophen

    • Albuterol

    • Dinoprostone

    • Sumatriptan

    • Misoprostol

    • Ibuprofen

    • Ergonovine

    Correct Answer
    A. Ibuprofen
    Explanation
    Primary dysmenorrhea is a cyclic pain associated with menses during ovulatory cycles, but
    without demonstrable lesions affecting the reproductive cycle. The pain is thought to results
    from uterine contraction and ischemia, most likely mediated by the actions of prostaglandins
    produced by the secretory endometrium. NSAIDs taken 2 days before menses and continued
    2-3 days thereafter, represent the drugs of choice. Propionic acid derivatives appears to be
    very effective since good to complete pain relief was reported for 42 to 100% of women using
    ibuprofen, in many clinical trials.
    A) Even if acetaminophen is advertised as an analgesic for dysmenorrhea, it is much less
    effective
    than NSAIDs because it is a very poor inhibitor of cyclooxygenase in peripheral tissues.
    B) Beta-2 agonists can relax the uterus but their action is much less effective than that of
    NSAIDs in dysmenorrhea where prostaglandins play the main role.
    C, D, E; G) These drugs actually would increase, not decrease, uterine contractions.

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  • 10. 

    A 44-year-old woman was found to have a plasma urate levels of 13 mg/dl and 800 mg/24 hrs of uric acid in her urine, during a routine checkup. She started an appropriate treatment and three weeks later her plasma urate levels were 7.2 mg/dL and the urinary uric acid level 530 mg/24 hrs. Which of the following drugs was most likely prescribed?

    • Probenecid

    • Aspirin

    • Furosemide

    • Allopurinol

    • Indomethacin

    • Naproxen

    Correct Answer
    A. Allopurinol
    Explanation
    Since urate levels are decreased after therapy both in plasma and in the urine, the drug must
    have decreased the formation of uric acid. Allopurinol inhibits the conversion of hypoxanthine to
    xanthine and xanthine to uric acid, so decreasing uric acid formation.
    A) Probenecid increases the renal excretion of uric acid and would have decreased uric acid in
    plasma but would have increased uric acid in the urine (so causing uricosuria).
    B) Aspirin would have decreased uric acid secretion at low/intermediate doses (so causing
    hyperuricemia) and would have increased secretion at high doses (so causing uricosuria).
    C) Furosemide can cause hyperuricemia.
    E, F) These drugs have negligible effects on uric acid secretion.

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  • 11. 

    A 66-year-old man complained to his physician that he did not urinate for the last 24 hours. The man was being treated with digoxin and furosemide for exacerbation of congestive heart failure and the therapy improved his cardiac conditions. Two days ago the patient had pain on movement of his left leg that improved with indomethacin. The physician found no clinical signs of intravascular volume depletion and increased the furosemide dose without any effect. Which of the following was the most likely reason of oliguria in this patient?

    • Indomethacin-mediated renal vasoconstriction

    • Worsening of cardiac failure in spite of the therapy

    • Furosemide-induced increase in angiotensin II secretion

    • Digoxin overdose toxicity

    • Furosemide-induced hypokalemia

    Correct Answer
    A. Indomethacin-mediated renal vasoconstriction
    Explanation
    Normally renal blood flow is maintained by a balance between renal vasoconstrictors
    (angiotensin II, norepinephrine) and renal vasodilators (prostaglandin E, prostacyclin). In
    cardiac failure circulating angiotensin II and norepinephrine are increased. In this setting the
    administration of a NSAID can remove renal vasodilator influences and result in
    profound vasoconstriction. In addition it has been shown that NSAIDs inhibit the diuretic
    effect of most diuretic agents, which explains why even an increase in furosemide dosage had
    no effect.
    B) Worsening of cardiac failure can be associated with oliguria, but this is unlikely in the
    present case since the patient did show improvement with therapy.
    C) Furosemide can increase angiotensin II secretion, secondary to the inhibition of NA+ and Cltransport
    into the macula densa, but this in turn normally stimulates prostaglandin secretion so
    that the final effect of furosemide is usually vasodilation of renal vascular bed.
    D) Oliguria is not a prominent sign of digoxin toxicity
    E) Severe hypokalemia impairs the concentrating ability of the kidney and therefore tend to
    cause polyuria, not oliguria.

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  • 12. 

    A 850 gm male, prematurely born at 27 weeks gestational age, was intubated immediately and placed on positive pressure assisted ventilation. On the third day of life his nurse noticed that he had tachycardia and a widened pulse pressure. Echocardiography was performed and showed a significant left-to-right shunting. An IV drug treatment was started. Which of the following drugs was most likely administered?

    • Alprostadil

    • Verapamil

    • Indomethacin

    • Acetaminophen

    • Furosemide

    • Propranolol

    Correct Answer
    A. Indomethacin
    Explanation
    The signs and symptoms of the boy strongly suggest that he has a patent ductus arteriosus,
    which can occur in up to 80% of premature infants with a birth weight less than 1200 g. In
    uterus patency of ductus arteriosus is maintained by the low Po2 and by the high concentration
    of prostaglandins, mainly PGE1, PGE2 and PGI2, which have vasodilatory actions. Because of
    this, NSAIDs have been found to speed up the closure of ductus arteriosus in newborn babies.
    Indomethacin given IV is the treatment of choice and can achieve the closure in more than
    70% of neonates.
    A) Actually alprostadil (PGE1) can maintain the patency of ductus arteriosus and is sometimes
    used for this purpose in neonates with congenital heart disease, until surgery can be
    performed.
    B, D, E, F) These drug have no effect on patency of ductus arteriosus.

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  • 13. 

    A 45-year-old man complained to his physician of severe pain at the base of his left big toe which had kept him awake the previous night. He described the pain as excruciating. On physical examination the first metatarsophalangeal joint was warm and tender, and the entire periarticular area was red and swollen. Which of the following drugs would be most appropriate to treat the patient pain?

    • Propoxyphene

    • Indomethacin

    • Auranofin

    • Aspirin

    • Probenecid

    • Allopurinol

    Correct Answer
    A. Indomethacin
    Explanation
    The symptoms and signs of the patient suggest that he is suffering from an acute gouty attack.
    Indomethacin is commonly prescribed for the treatment of acute attack of gout and many
    consider it to be the drug of choice. Colchicine is another drug highly effective in the gouty
    attack, but is less frequently used today because of its potential adverse effects.
    A) The analgesic action of propoxyphene (an opioid analgesic) is too weak to be useful in the
    gouty attack.
    C) Gold compounds are useful in rheumatoid arthritis but are without effect in gouty arthritis.
    D) NSAIDs other than indomethacin have been proved effective in the treatment of acute gouty
    arthritis. Aspirin however can inhibit (when given in small doses) the excretion of uric acid by
    the kidney and therefore should not be used for analgesia in patients with gout.
    E, F) These drugs can decrease uric acid plasma levels in patients with gout but they cannot
    relieve the pain of a gouty attack.

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  • 14. 

    A 55-year-old man, who suffered in the past from gastric ulcer, has been recently diagnosed with rheumatoid arthritis and is now taking the antiinflammatory drug prescribed by his physician. Which of the following drugs is he most likely taking?

    • Ibuprofen

    • Piroxicam

    • Indomethacin

    • Ketorolac

    • Celecoxib

    • Aspirin

    Correct Answer
    A. Celecoxib
    Explanation
    Celecoxib is a selective inhibitor of cyclooxygenase 2. Drugs of this class (sometimes called
    oxibs) have analgesic, antipyretic and antiinflammatory actions. However their lack action on
    platelet aggregation and have minimal adverse effects on gastric mucosa. These drugs are
    therefore preferred in patients at risk of peptic ulcer disease, like in the present case.
    A, B, C, D, F) (see explanation above)

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  • 15. 

    A 52-year-old man was seen in the clinic for a routine evaluation. Two years ago the patient had an operation to remove a big renal calculus. Last year he had two episodes of renal colic apparently due to small calculi located in the left ureter. Lab values on admission were: potassium 4.9 mEq/L, creatinine 2.8 mg/dL, uric acid 16 mg /dL, BUN 38 mg/dL. Which of the following drugs would be appropriate for this patient?

    • Probenecid

    • Furosemide

    • Hydrochlorothiazide

    • Allopurinol

    • Indomethacin

    Correct Answer
    A. Allopurinol
    Explanation
    The patient has hyperuricemia that was likely the cause of renal calculi, which could have played a
    role (intrarenal precipitation of urates) in the border-line renal insufficiency (elevated BUN). Drugs
    that decrease uric acid formation (allopurinol) or that increase uric acid secretion (probenecid) can
    be used to treat hyperuricemia.
    A) In this patient, however, probenecid is contraindicated because an increased concentration of
    uric acid in the urine could favor the formation of urate calculi.
    B, C) These diuretics are contraindicated because they tend to cause hyperuricemia.
    E) Indomethacin is used to treat acute gout but is not effective against hyperuricemia

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  • 16. 

    A 33-year-old man suffering from hemophilia has been recently diagnosed with tension headache. The headache occurs two to four times weekly, usually toward the end of his work day. The pain is constant, dull in character and usually lasts the rest of the day with variable intensity. Which of the following drug would be appropriate for this patient?

    • Indomethacin

    • Acetaminophen

    • Aspirin

    • Ketorolac

    • Piroxicam

    • Naproxen

    Correct Answer
    A. Acetaminophen
    Explanation
    Since the patient is suffering from hemophilia all NSAIDs are contraindicated since they can
    decrease platelet aggregation and can provoke gastrointestinal bleeding. Acetaminophen is
    free from the above mentioned effects and can be use as analgesic in this patient.
    A, C, D, E, F) (see explanation above)

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  • 17. 

    A 8-year-old boy presented with fever (103° F), general malaise and the characteristic rash of measles infection. Past medical history of the patient included an episode of hemolytic anemia, most probably related to his congenital deficiency of RBC glutathione synthase. Which of the following drugs would be a suitable antipyretic for this boy?

    • Aspirin

    • Indomethacin

    • Acetaminophen

    • Ibuprofen

    • Prednisone

    Correct Answer
    A. Ibuprofen
    Explanation
    Ibuprofen has been approved for use as an antipyretic in children and is currently available
    over the counter. All NSAIDs have antipyretic activity and therefore the initial choice is often
    based on specific patient related contraindications. In fact in this patient:
    A) Aspirin is contraindicated because of the risk of Reye’s syndrome. This serious disorders
    affects mainly children or young adults and predisposing factors include salicylate therapy.
    B) Indomethacin is not indicated for general use as analgesic or antipyretic because of its
    toxicity.
    C) Acetaminophen is contraindicated in this patient because of his congenital deficiency of
    RBC glutathione synthase. Acetaminophen is partially metabolized to N-acetyl-p-benzoquinone
    which is rapidly conjugated with glutathione. If glutathione stores are deficient, the metabolite
    reacts with hepatocyte macromolecules, resulting in hepatotoxicity. Patients with congenital
    deficiency of glutathione synthase are therefore at increased risk of acetaminophen toxicity.
    E, F) These drugs are not used as antipyretics.

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  • 18. 

    A 34-year-old man, recently diagnosed with a diffuse, poorly differentiated lymphoma, was admitted to the hospital and began the first cycle of chemotherapy. One day later he became anuric. Pertinent blood values were: potassium 6.9 mEq/L, calcium 6.4 mg/dL, Phosphorus 5.4 mg/dL, creatinine 3.8 mg/dL, uric acid 26 mg/dL, BUN 62 mg/dL. A pretreatment with which of the following drugs would likely have been avoided the patient’s anuria?

    • Hydrochlorothiazide

    • Spironolactone

    • Furosemide

    • Probenecid

    • Allopurinol

    Correct Answer
    A. Allopurinol
    Explanation
    The patient most likely had the tumor lysis syndrome which develops following the institution of
    systemic chemotherapy for rapidly growing bulky tumors. The syndrome is most often observed in
    patients with certain types of lymphoma (acute lymphoblastic, diffuse undifferentiated, Burkitt’s) or
    acute lymphocytic leukemia. Rapid lysis of tumor leads to release of intracellular uric acid,
    potassium and phosphate with resultant hyperuricemia, hyperkalemia, hyperphosphatemia and
    hypocalcemia (secondary to calcium and phosphate precipitation in the presence of an elevated
    serum phosphorus). Renal failure may result from uric acid and /or calcium phosphate deposition
    in the renal tubules. In the present patient, since serum phosphorus and calcium are normal, renal
    failure (which is also indicated by the high creatinine and BUN values) is most likely due to urate
    precipitation in renal tubules. All patients undergoing intensive chemotherapy should be pretreated
    with allopurinol to prevent hyperuricemia. All the other listed drugs cannot prevent hyperuricemia
    and moreover they are all contraindicated because:
    A) Hydrochlorothiazide can cause hyperuricemia.
    B) Spironolactone can cause hyperkalemia.
    C) Furosemide can cause hypocalcemia.
    D) Probenecid would increase urate excretion and therefore the risk of urate precipitation in renal
    tubules.

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  • 19. 

    A 50-year-old woman presented to the hospital with a pruritic rash on her abdomen, a bluish grey skin pigmentation and stomatitis. The woman, recently diagnosed with rheumatoid arthritis, was initially prescribed ibuprofen but three months ago her disease was still progressing and the physician added another drug to her regimen. Urinalysis upon admission showed albuminuria and microscopic hematuria. Which of the following drugs most likely caused the patient’s signs and symptoms?

    • Auranofin

    • Naproxen

    • Chloroquine

    • Prednisone

    • Piroxicam

    • Aspirin

    Correct Answer
    A. Auranofin
    Explanation
    The signs and the history of the patient suggest that she was treated with a gold compound. These
    agents are employed in the treatment of rheumatoid arthritis in an attempt to arrest the progress of
    the disease and to induce remission. Gold compounds cause a high incidence of toxicity. The
    most common adverse effect (which occur in 15-20 % of patients) involve the skin and mucous
    membranes, usually the mouth. A gray-to-blue pigmentation may also occur in the skin, like in the
    present case. Kidney function may also be affected in about 10% of patient.
    B, C, D, E, F) All these drugs can be used in rheumatoid arthritis but they do not cause the pattern
    of adverse effect presented by the patient.

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  • 20. 

    A 75-year-old man complains of a dull, continuous bone pain which has been increasing during the past few days. The patient has been suffering from a prostatic carcinoma for two years. Past history of the patient is significant for an episode of hemolytic anemia, which was ascribed to his congenital G6PD deficiency, and erythema multiforme, apparently due to an allergic reaction to naproxen. Which of the following would be an appropriate analgesic drug for this patient?

    • Aspirin

    • Acetaminophen

    • Piroxicam

    • Ibuprofen

    • Propoxyphene

    • Amitriptyline

    Correct Answer
    A. Piroxicam
    Explanation
    The symptoms and the history of the patient suggest that the pain is caused by bone
    metastases that are the most frequent metastases in case of prostatic carcinoma. Osseous
    metastases induce an inflammatory reaction with the production of prostaglandins that may
    cause osteolysis and sensitize free nerve ending so augmenting pain perception. The NSAIDs
    effectively decrease prostaglandin and endoperoxide production and therefore can be useful
    for an initial treatment of metastatic bone pain. Piroxicam is a long-acting, nonselective
    competitive inhibitor of cyclooxygenase that also inhibits polymorphonuclear cell migration and
    decreases oxygen radical production. Likely all NSAIDs would be useful, and the superiority of
    any particular drug for a particular patient cannot be predicted. Therefore the initial choice is
    often based on specific patient related contraindications. In fact in this patient:
    A) Aspirin is contraindicated because of his congenital G6PD deficiency (salicylates can cause
    hemolytic anemia in patients with this deficiency)
    B) Acetaminophen is a very weak inhibitor of cyclooxygenase in the presence of a high
    concentration of peroxide that are found in inflammatory lesions.
    D) All propionic acid derivatives are contraindicated because of the serious allergic reaction to
    naproxen.
    E) Propoxyphene is a very weak opioid analgesic that would be less effective in bone
    metastases where the pain is mainly related to the inflammatory reaction.
    F) Tricyclic antidepressant like amitriptyline are sometime useful analgesics in neoplastic
    disorders when the pain is neuropathic (i.e. due to the damage of neuronal structures) but mot
    so when the pain is nociceptive (i.e. pain transmitted over intact neural pathways) like in the
    present case.

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    Quiz Created by
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