Acetaminophen is the only drug that fits this description. Indomethacin is a nonselective COX inhibitor and celecoxib is a COX-2 inhibitor; both have analgesic, antipyretic, and anti-inflammatory effects. Colchicine is a drug used for gout that also has an anti-inflammatory action. Probenecid is a uricosuric drug that promotes the excretion of uric acid. The answer is A.

A 16-year-old girl comes to the emergency department suffering from the effects of an aspirin overdose. Which of the following syndromes is this patient most likely to exhibit as a result of this drug overdose?

(A) Bone marrow suppression and possibly aplastic anemia

(B) Fever, hepatic dysfunction, and encephalopathy

(C) Hyperthermia, metabolic acidosis, and coma

(D) Rapid, fulminant hepatic failure

(E) Rash, interstitial nephritis, and acute renal failure

Salicylate intoxication is associated with metabolic acidosis, dehydration, and hyperthermia. If these problems are not corrected, coma and death ensue. The answer is C.

Which of the following drugs is most likely to increase serum concentrations of conventional doses of methotrexate, a weak acid that is primarily cleared in the urine?

(A) Acetaminophen

(B) Allopurinol

(C) Colchicine

(D) Hydroxychloroquine

(E) Probenecid

Like other weak acids, methotrexate depends on active tubular excretion in the proximal tubule for efficient elimination. Probenecid competes with methotrexate for binding to the proximal tubule transporter and thereby decreases the rate of clearance of methotrexate. The answer is E.

The main advantage of ketorolac over aspirin is that ketorolac

(A) Can be combined more safely with an opioid such as codeine

(B) Can be obtained as an over-the-counter agent

(C) Does not prolong the bleeding time

(D) Is available in a parenteral formulation that can be injected intramuscularly or intravenously

(E) Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment

Ketorolac exerts typical NSAID effects. It prolongs the bleeding time and can impair renal function, especially in a patient with preexisting renal disease. Its primary use is as a parenteral agent for pain management, especially for treatment of postoperative patients. The answer is D.

An 18-month-old boy dies from an accidental overdose of acetaminophen. Which of the following is the most likely cause of this patient’s death?

(A) Arrhythmia

(B) Hemorrhagic stroke

(C) Liver failure

(D) Noncardiogenic pulmonary edema

(E) Ventilatory failure

In overdose, acetaminophen causes fulminant liver failure as a result of its conversion by hepatic cytochrome P450 enzymes to a highly reactive metabolite. The answer is C.

A 52-year-old woman presented with intense pain, warmth, and redness in the first toe on her left foot. Examination of fluid withdrawn from the inflamed joint revealed crystals of uric acid.

In the treatment of this woman’s acute attack of gout, a high dose of colchicine will reduce the pain and inflammation. However, many physicians prefer to treat acute gout with a corticosteroid or indomethacin because high doses of colchicine are likely to cause

(A) Behavioral changes that include psychosis

(B) High blood pressure

(C) Rash

(D) Severe diarrhea

(E) Sudden gastrointestinal bleeding

At doses needed to treat acute gout, colchicine frequently causes significant diarrhea. Such gastrointestinal effects are less likely with the lower doses used in chronic gout. The answer is D.

A 52-year-old woman presented with intense pain, warmth, and redness in the first toe on her left foot. Examination of fluid withdrawn from the inflamed joint revealed crystals of uric acid.

Over the next 7 mo, the patient had 2 more attacks of acute gout. Her serum concentration of uric acid was elevated. The decision was made to put her on chronic drug therapy to try to prevent subsequent attacks. Which of the following drugs could be used to decrease this woman’s rate of production of uric acid?

(A) Allopurinol

(B) Aspirin

(C) Colchicine

(D) Hydroxychloroquine

(E) Probenecid

Allopurinol is the only drug listed that decreases production of uric acid. Probenecid increases uric acid excretion. Colchicine and hydroxychloroquine do not affect uric acid metabolism. Aspirin actually slows renal secretion of uric acid and raises uric acid blood levels. It should not be used in gout. The answer is A.

A 54-year-old woman presented with signs and symptoms consistent with an early stage of rheumatoid arthritis. The decision was made to initiate NSAID therapy.

Which of the following patient characteristics is the most compelling reason for avoiding celecoxib in the treatment of her arthritis?

(A) History of alcohol abuse

(B) History of gout

(C) History of myocardial infarction

(D) History of osteoporosis

(E) History of peptic ulcer disease

Celecoxib is a COX-2-selective inhibitor. Although the COX-2 inhibitors have the advantage over nonselective NSAIDs of reduced gastrointestinal toxicity, clinical data suggest that they are more likely to cause arterial thrombotic events. A history of myocardial infarction would be a compelling reason to avoid a COX-2 inhibitor. The answer is C.

A 54-year-old woman presented with signs and symptoms consistent with an early stage of rheumatoid arthritis. The decision was made to initiate NSAID therapy.

Although the patient’s disease was adequately controlled with an NSAID and methotrexate for some time, her symptoms began to worsen and radiologic studies of her hands indicated progressive destruction in the joints of several fingers. Treatment with another second-line agent for rheumatoid arthritis was considered. Which of the following is a parenterally administered DMARD whose mechanism of anti-inflammatory action is antagonism of tumor necrosis factor?

(A) Cyclosporine

(B) Etanercept

(C) Penicillamine

(D) Phenylbutazone

(E) Sulfasalazine

Etanercept is a recombinant protein that binds to tumor necrosis factor and prevents its inflammatory effects. The answer is B.

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Chapter 36: NSAIDs, Acetaminophen, & Drugs Used in Rheumatoid Arthritis & Gout

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Chapter 36: NSAIDs, Acetaminophen, & Drugs Used in Rheumatoid Arthritis & Gout

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