A 69-year-old man comes to the office due to severe pain in his left knee for the past 48 hours. The pain began in the middle of the night. He has not had trauma, fever, or chills. He had an episode of pain in his right great toe 3 years ago that he was told was gout. He was given treatment to prevent a recurrence but has been noncompliant. Medical history is significant for hypertension, stage 3 chronic kidney disease, and gastroesophageal reflux disease (GERD) . His current medications are atenolol, fosinopril, and lansoprazole.
He appears to be in mild distress and has difficulty with ambulation. Temperature is 36.7 C (98 F) , blood pressure is 136/94 mm Hg, pulse is 84/min, and respirations are 14/min. Cardiovascular, pulmonary, and abdominal exams are unremarkable. His left knee is tender, warm, and erythematous with a small effusion. There is decreased range of motion in all aspects. There are no abnormalities of any other joints.
Laboratory results are as follows:
Plain films of the knee are remarkable only for evidence of degenerative joint disease.
On arthrocentesis of the left knee, a small amount of fluid was obtained with a negative gram stain and 13,000/mm³ white blood cells (50% polymorphonuclear cells) . Needle-shaped, negatively birefringent crystals are present on polarized microscopy.
Which of the following is the best treatment option for this patient?

Question

A 69-year-old man comes to the office due to severe pain in his left knee for the past 48 hours. The pain began in the middle of the night. He has not had trauma, fever, or chills. He had an episode of pain in his right great toe 3 years ago that he was told was gout. He was given treatment to prevent a recurrence but has been noncompliant. Medical history is significant for hypertension, stage 3 chronic kidney disease, and gastroesophageal reflux disease (GERD) . His current medications are atenolol, fosinopril, and lansoprazole.
He appears to be in mild distress and has difficulty with ambulation. Temperature is 36.7 C (98 F) , blood pressure is 136/94 mm Hg, pulse is 84/min, and respirations are 14/min. Cardiovascular, pulmonary, and abdominal exams are unremarkable. His left knee is tender, warm, and erythematous with a small effusion. There is decreased range of motion in all aspects. There are no abnormalities of any other joints.
Laboratory results are as follows:

Plain films of the knee are remarkable only for evidence of degenerative joint disease.
On arthrocentesis of the left knee, a small amount of fluid was obtained with a negative gram stain and 13,000/mm³ white blood cells (50% polymorphonuclear cells) . Needle-shaped, negatively birefringent crystals are present on polarized microscopy.
Which of the following is the best treatment option for this patient?

Quizplus · Accepted Answer

11ec193a_9911_7c0f_853d_9986daee078e_MD0002_00 This patient has acute gout, which usually causes mono-arthritis but can also affect multiple joints in some patients. The goal of therapy is acute pain relief with prompt resolution. Prophylactic treatment is indicated for the prevention of future attacks, chronic tophaceous gout, and avoidance of joint disability. The table above summarizes the main therapies for acute gout. This patient with chronic kidney disease (CKD) has a mono-articular flare of gout, and intra-articular corticosteroids are the most effective and safest therapy. When systemic corticosteroids are used, there is a risk of rebound attacks once the drug is discontinued. (Choice A) Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production and prevents recurrent attacks of gouty arthritis; it is typically considered in patients with frequent attacks (eg, ≥2 attacks/year, although exact definitions vary). The dose of allopurinol must be decreased in patients with CKD (GFR <30-50 mL/min) because its metabolite (oxypurinol) can accumulate in the body and cause serious liver function abnormalities and a severe desquamating skin rash. (Choice B) Febuxostat is a nonpurine inhibitor of xanthine oxidase, which decreases serum levels of uric acid and is less dependent on renal elimination than allopurinol. Febuxostat is used to treat chronic hyperuricemia and prevent gouty arthritis, but is not indicated for acute gout. (Choice C) Indomethacin and other NSAIDs are preferred for treating acute gouty arthritis, but they cause acute kidney injury (AKI) by decreasing renal blood flow and GFR (due to decreased production of vasodilatory eicosanoids). As a result, NSAIDs are contraindicated in this patient with stage 3 CKD. (Choice E) Colchicine is effective for acute gouty arthritis, but is limited by frequent gastrointestinal side effects and is a second-line agent. Colchicine is less effective than corticosteroids. Chronic administration in CKD patients can lead to colchicine accumulation in the blood and cause significant neuromyopathy. Educational objective: NSAIDs are the preferred agents for acute gout, but steroids (intra-articular or systemic) are safer and preferred in patients with chronic kidney disease. Colchicine is not recommended in patients with chronic kidney disease. Allopurinol and febuxostat should not be used for acute attacks, but they are both helpful in the prevention of future attacks. __________ References: Systemic corticosteroids for acute gout (http://www.ncbi.nlm.nih.gov/pubmed/18425920) Managing gout: How is it different with chronic kidney disease? (http://www.ncbi.nlm.nih.gov/pubmed/21147946)

A 69-Year-Old Man Comes to the Office Due to Severe