A 75 year old man was admitted to hospital for shortness of breath, productive cough and fever. The diagnoses were acute pulmonary edema and pneumonia. He had past medical history of hypertension, diabetes mellitus, chronic kidney disease (plasma urea: 16.9 mmol/L; plasma creatinine: 315 micromol/L; estimated glomerular filtration rate (GFR) by MDRD equation: 24 mL/min per 1.73 m2), gouty arthritis, atrial fibrillation, and old stroke. He had been using warfarin anticoagulation therapy for secondary prevention of thromboembolism. After intravenous frusemide diuretic therapy, the acute pulmonary edema subsided. However, he was complicated by acute gouty attack over his knees and ankles, which were improved with colchicine therapy. Colchicine (0.5 mg twice daily) was prescribed for 30 days on hospital discharge. Yet he was readmitted to hospital again three weeks later for diarrhea, lower limbs weakness and fall.

a)

i) Name FOUR pharmacotherapeutic options for management of acute gouty arthritis. (4 marks)

ii) Name ONE caution or contra indication for EACH of the therapeutic options listed above in this elderly patients with multiple comorbidities (4 marks)

b) What is the colchicine regime for treatment of acute gout flares (2 marks)

c)

i) Name ONE antibiotic for treatment of pneumonia that should be avoided while the patient was on colchicine therapy (1 mark)

ii) Explain the mechanism of drug-drug interaction involved (1 mark)

d) What are the dosages of colchicine for prophylactic gout treatments in patients with chronic kidney disease with CrCl > 30 ml/min and < 30 ml/min respectively? (2 marks)

e) Name FOUR toxicities of colchicine poisoning (2 marks)

f) Name other FOUR uric acid lowering therapies that can be used for treatment of chronic gout (2 marks)

g) Name ONE serious cutaneous adverse reactions that can occur in chronic kidney disease patients with allopurinol therapy. (1 mark) 

h) What pharmacogenetics screening test can be useful to detect higher risk of severe cutaneous adverse reactions in Han Chinese with allopurinol therapy? (1 mark)