A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 55-year-old man presents to the urgent clinic complaining of pain in his right foot. He reported that the pain is intense that he had to remove his shoe and sock, and rates the pain level as 6 out of 10. He does not report trauma or recent infection. The past medical history includes hypertension. The medications include hydrochlorothiazide, enalapril, and a daily multivitamin. The family history is noncontributory. He consumes alcohol in moderation. His diet mostly consists of red meat and white rice. The blood pressure is 137/85 mm Hg, heart rate is 74/min, respiratory rate is 12/min, and the temperature is 36.9°C (98.4°F). The physical examination demonstrates swelling, redness, and tenderness to palpation in the first metatarsophalangeal joint of his right foot. There are no skin lesions. The rest of the patient’s examination is normal. An arthrocentesis procedure is scheduled. Which of the following is the most likely pharmacological treatment for the presented patient?
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A
Probenecid aloneIncorrect. Probenecid is a uricosuric for chronic urate lowering between flares — starting it during an acute attack can worsen the flare.
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B
Oral methylprednisolone and meloxicamIncorrect. Stacking oral steroid + meloxicam is unnecessary for an uncomplicated acute gout flare; monotherapy is standard.
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C
Colchicine and celecoxibIncorrect. Colchicine + celecoxib combination is overkill; either alone is sufficient for acute flare. Colchicine is reserved for NSAID-intolerant patients.
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D
Diclofenac aloneCorrect. NSAID monotherapy (diclofenac, indomethacin, or naproxen) at full anti-inflammatory dose is first-line for acute gout in patients without contraindications.
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E
Intra-articular hyaluronic acidIncorrect. Intra-articular hyaluronic acid is used for osteoarthritis symptom relief, not for acute crystal arthropathy; it doesn't address the inflammatory crystal-induced flare.
↑ Tap an answer to reveal the reasoning
Answer: D. This patient has acute monoarticular arthritis of the first metatarsophalangeal (podagra), red and tender — classic acute gouty arthritis. Risk factors are present: hypertension on hydrochlorothiazide (a thiazide diuretic that elevates uric acid), moderate alcohol intake, and a diet high in red meat (purine-rich). Arthrocentesis is scheduled, which is appropriate to confirm by visualizing negatively birefringent needle-shaped monosodium urate crystals.
For acute gout flares, first-line therapy is an NSAID (such as diclofenac, indomethacin, or naproxen) at full anti-inflammatory dose — provided there's no contraindication (renal insufficiency, peptic ulcer, anticoagulation). This patient has no listed contraindications and his BP and renal function aren't grossly impaired.
Probenecid is a uricosuric used for chronic urate-lowering therapy, NOT acute attacks — and starting urate-lowering during an acute flare can worsen it. Combining oral steroids and meloxicam is unnecessary stacking. Combining colchicine and celecoxib is also overkill — monotherapy with an NSAID is sufficient for an uncomplicated acute flare. Colchicine is an alternative to NSAIDs (especially in NSAID-contraindicated patients), and steroids are useful when both NSAIDs and colchicine are contraindicated — but here NSAID monotherapy (diclofenac) is sufficient and first-line.
**Why each option:**
**A.** Probenecid is a uricosuric for chronic urate lowering between flares — starting it during an acute attack can worsen the flare.
**B.** Stacking oral steroid + meloxicam is unnecessary for an uncomplicated acute gout flare; monotherapy is standard.
**C.** Colchicine + celecoxib combination is overkill; either alone is sufficient for acute flare. Colchicine is reserved for NSAID-intolerant patients.
**D.** Correct. NSAID monotherapy (diclofenac, indomethacin, or naproxen) at full anti-inflammatory dose is first-line for acute gout in patients without contraindications.