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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}, {{AJL}} {{Alison}}
|QuestionAuthor={{YD}} (Reviewed by {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pharmacology
|MainCategory=Pharmacology
Line 8: Line 8:
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|SubCategory=Renal
|SubCategory=Renal
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
|MainCategory=Pharmacology
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|MainCategory=Pharmacology
|MainCategory=Pharmacology
|SubCategory=Renal
|SubCategory=Renal
|Prompt=A 72-year-old male presents to your office with dyspnea and bilateral pitting edema. His medical history is significant for diabetes mellitus, gout, and osteoarthritis. Upon further questioning, the patient tells you he cannot tolerate several medications because he is allergic.  He recalls that he developed a skin rash when he used sulfonylurea, probenicid, celecoxib, and sulfonamide antibiotics. Nonetheless, you decide to prescribe him a diuretic to relieve his symptoms.  Which of the following diuretics is the best option for this patient?
|Prompt=A 72-year-old man presents to the physician's office with complaints of dyspnea and bilateral pitting edema. His past medical history is significant for diabetes mellitus, gout, and osteoarthritis. Upon further questioning, the patient explains that he is allergic to several medications. Among the list of medications that he has tried in the past, he recalls he developed skin rash when he was administered sulfonylurea, probenicid, celecoxib, and sulfonamide antibiotics. Following appropriate work-up, the patient is diagnosed with congestive heart failure. The physician decides to prescribe diuretic therapy to relieve the patient's symptoms.  Which of the following diuretics is the optimal therapeutic option to treat this patient's congestive heart failure?
|Explanation=[[Sulfa allergy]] is a term that describes adverse drug reactions to a list of several medications.  Sulfa allergy is typically seen in the following medications: [[Sulfonamide]], [[sulfasalazine]], [[sulfonylurea]], [[celecoxib]], [[probenicid]], and diuretics such as [[furosemide]], [[acetazolamide]], and [[thiazides-type diuretics]].
|Explanation=[[Sulfa allergy]] is a term that describes adverse drug reactions to sulfanamide-based (sulfa) medications.  The following list of medications are common sulfa drugs:<br>
 
*Sulfonamide antibiotics: sulfanilamide, sulfoxazole, sulfamylon, sulfamethoxazole-trimethoprim (associated with the most severe hypersensitivity reactions)
Sulfa allergy has an incidence rate of less than 5% among the general population. It has a range of manifestations from very mild to fatal. Symptoms include skin rash, hepatic, renal, and pulmonary injury, and hematologic disturbances, such as [[thrombocytopenia]], [[leucopenia]], and [[hemolytic anemia]]. Treatment of sulfa allergy includes stopping the offending medications and symptomatic treatment of its manifestations until resolution.
*Diuretics:<br>
In patients who require dieresis, [[ethacrynic acid]], a phenoxyacetic acid derivative, is a loop diuretic that is not associated with sulfa allergy. Because it is frequently associated with [[ototoxicity]], it is usually only reserved for patients who are known to have sulfa allergy.
**Acetazolamide
 
**Loop diuretics: Furosemide, bumetanide
|EducationalObjectives=
**Thiazide-diuretics: Hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide
[[Ethacrynic acid]] is a helpful diuretic in patients with sulfa allergy. Sulfa allergy is a range of skin, visceral, and hematological manifestations that occur following intake of some medications. Sulfa allergy symptoms might range from very mild to very severe.
*Sulfonylureas: Glyburide, chlorpropamide, gliclazide, glimepiride, tolbutamide
 
*NSAIDs: Celecoxib and valdecoxib
|References= Wall GC, Bigner D, Craig S. Ethacrynic acid and the sulfa-sensitive patient. Arch Intern Med. 2003;163(1):116-117.
*Uricosuric agents: Probenecid
*Antimigraine agents:<br>
**Triptans: Sumatriptan, naratriptan
*Anticonvulsants: Topiramate
*Antiarrhythmic agents<br>
**Class III agents: Sotalol, ibutilide
*Others: Dapsone, sulfasalazine
Sulfa allergy has an incidence rate of less than 5% among the general population. Clinical manifestations range from a very mild clinical course to potentially fatal outcomes. Symptoms of sulfa hypersensitivity include fever, skin rash (maculopapular rash or fixed drug eruption that often develops 1 or 2 weeks following drug administration) along with hepatic, renal, pulmonary, and hematological (thrombocytopenia, leukopenia/agranulocytosis, hemolytic anemia) manifestations. The first step in the management of sulfa allergy is stopping the offending medications followed by symptomatic treatment of the hypersensitivity manifestations until complete resolution. Among patients who require dieresis (such as patients with advanced congestive heart failure), [[ethacrynic acid]], a phenoxyacetic acid derivative, is a loop diuretic that is not associated with sulfa allergy and may be prescribed to patients with sulfa allergy to symptomatic relief of fluid overload. However, ethacrynic acid is associated with high rates of [[ototoxicity]] and is usually only reserved for patients who are known to have sulfa allergy.
|AnswerA=Furosemide
|AnswerA=Furosemide
|AnswerAExp=[[Furosemide]], a [[loop diuretic]], commonly causes sulfa allergy.
|AnswerAExp=[[Furosemide]] is a [[loop diuretic]] that is associated with sulfa allergy.
|AnswerB=Acetazolamide
|AnswerB=Acetazolamide
|AnswerBExp=[[Acetazolamide]], a carbonic anhydrase inhibitor, commonly causes sulfa allergy.
|AnswerBExp=[[Acetazolamide]] is carbonic anhydrase inhibitor that is associated with sulfa allergy.
|AnswerC=Ethacrynic acid
|AnswerC=Ethacrynic acid
|AnswerCExp=[[Ethacrynic acid]] is a diuretic often prescribed to patients with sulfa allergy.
|AnswerCExp=[[Ethacrynic acid]] is a loop diuretic often prescribed to patients with sulfa allergy.
|AnswerD=Hydrochlorothiazide
|AnswerD=Hydrochlorothiazide
|AnswerDExp=[[Hydrochlorothiazide]] is a thiazides-type diuretic. [[Thiazide]]s are associated with sulfa allergy.
|AnswerDExp=[[Hydrochlorothiazide]] is a thiazides-type diuretic. Some [[thiazide]] diuretics are associated with sulfa allergy.
|AnswerE=Chlorthalidone
|AnswerE=Chlorthalidone
|AnswerEExp=Chlorthalidone is also a thiazides-type diuretic. [[Thiazide]]s are associated with sulfa allergy.
|AnswerEExp=Chlorthalidone is also a thiazides-type diuretic. Some [[thiazide]] diuretics are associated with sulfa allergy.
|EducationalObjectives=[[Ethacrynic acid]] is a loop diuretic often prescribed to patients with sulfa allergy for symptomatic relief of fluid overload. Features of sulfa allergy include skin, visceral, hematological, and constitutional manifestations.
|References=Wall GC, Bigner D, Craig S. Ethacrynic acid and the sulfa-sensitive patient. Arch Intern Med. 2003;163(1):116-117.
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Sulfa drug allergy, diuretics, ethacrynic acid,
|WBRKeyword=Sulfa allergy, Diuretics, Ethacrynic acid, Sulfa drug, Hypersensitivity, Congestive heart failure
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 22:07, 17 February 2015
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pharmacology
Sub Category SubCategory::Renal
Prompt [[Prompt::A 72-year-old man presents to the physician's office with complaints of dyspnea and bilateral pitting edema. His past medical history is significant for diabetes mellitus, gout, and osteoarthritis. Upon further questioning, the patient explains that he is allergic to several medications. Among the list of medications that he has tried in the past, he recalls he developed skin rash when he was administered sulfonylurea, probenicid, celecoxib, and sulfonamide antibiotics. Following appropriate work-up, the patient is diagnosed with congestive heart failure. The physician decides to prescribe diuretic therapy to relieve the patient's symptoms. Which of the following diuretics is the optimal therapeutic option to treat this patient's congestive heart failure?]]
Answer A AnswerA::Furosemide
Answer A Explanation [[AnswerAExp::Furosemide is a loop diuretic that is associated with sulfa allergy.]]
Answer B AnswerB::Acetazolamide
Answer B Explanation [[AnswerBExp::Acetazolamide is carbonic anhydrase inhibitor that is associated with sulfa allergy.]]
Answer C AnswerC::Ethacrynic acid
Answer C Explanation [[AnswerCExp::Ethacrynic acid is a loop diuretic often prescribed to patients with sulfa allergy.]]
Answer D AnswerD::Hydrochlorothiazide
Answer D Explanation [[AnswerDExp::Hydrochlorothiazide is a thiazides-type diuretic. Some thiazide diuretics are associated with sulfa allergy.]]
Answer E AnswerE::Chlorthalidone
Answer E Explanation [[AnswerEExp::Chlorthalidone is also a thiazides-type diuretic. Some thiazide diuretics are associated with sulfa allergy.]]
Right Answer RightAnswer::C
Explanation [[Explanation::Sulfa allergy is a term that describes adverse drug reactions to sulfanamide-based (sulfa) medications. The following list of medications are common sulfa drugs:
  • Sulfonamide antibiotics: sulfanilamide, sulfoxazole, sulfamylon, sulfamethoxazole-trimethoprim (associated with the most severe hypersensitivity reactions)
  • Diuretics:
    • Acetazolamide
    • Loop diuretics: Furosemide, bumetanide
    • Thiazide-diuretics: Hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide
  • Sulfonylureas: Glyburide, chlorpropamide, gliclazide, glimepiride, tolbutamide
  • NSAIDs: Celecoxib and valdecoxib
  • Uricosuric agents: Probenecid
  • Antimigraine agents:
    • Triptans: Sumatriptan, naratriptan
  • Anticonvulsants: Topiramate
  • Antiarrhythmic agents
    • Class III agents: Sotalol, ibutilide
  • Others: Dapsone, sulfasalazine

Sulfa allergy has an incidence rate of less than 5% among the general population. Clinical manifestations range from a very mild clinical course to potentially fatal outcomes. Symptoms of sulfa hypersensitivity include fever, skin rash (maculopapular rash or fixed drug eruption that often develops 1 or 2 weeks following drug administration) along with hepatic, renal, pulmonary, and hematological (thrombocytopenia, leukopenia/agranulocytosis, hemolytic anemia) manifestations. The first step in the management of sulfa allergy is stopping the offending medications followed by symptomatic treatment of the hypersensitivity manifestations until complete resolution. Among patients who require dieresis (such as patients with advanced congestive heart failure), ethacrynic acid, a phenoxyacetic acid derivative, is a loop diuretic that is not associated with sulfa allergy and may be prescribed to patients with sulfa allergy to symptomatic relief of fluid overload. However, ethacrynic acid is associated with high rates of ototoxicity and is usually only reserved for patients who are known to have sulfa allergy.
Educational Objective: Ethacrynic acid is a loop diuretic often prescribed to patients with sulfa allergy for symptomatic relief of fluid overload. Features of sulfa allergy include skin, visceral, hematological, and constitutional manifestations.
References: Wall GC, Bigner D, Craig S. Ethacrynic acid and the sulfa-sensitive patient. Arch Intern Med. 2003;163(1):116-117.]]

Approved Approved::Yes
Keyword WBRKeyword::Sulfa allergy, WBRKeyword::Diuretics, WBRKeyword::Ethacrynic acid, WBRKeyword::Sulfa drug, WBRKeyword::Hypersensitivity, WBRKeyword::Congestive heart failure
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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