A 55-year-old man with a history of gout comes to the physician because of progressively worsening pain and swelling in his right knee that started overnight. The patient took two over-the-counter ibuprofen tablets earlier in the day, which were ineffective. He was diagnosed with gout six months ago when he had an ankle effusion, and he was started on allopurinol at that time. His other medical problems include recurrent renal stones, hypertension, and chronic rotator cuff tendinitis. His home medications include benazepril and allopurinol 100 mg daily.
On examination, the right knee appears swollen and tender.
Laboratory studies show a white blood cell count of 12,200 cells/µL, serum creatinine of 1.1 mg/dL, uric acid level of 9 mg/dL (11 mg/dL 6 months ago), and normal liver function tests. Knee aspiration reveals monosodium urate crystals.
Which of the following is the best next step in managing this patient?

Question

A 55-year-old man with a history of gout comes to the physician because of progressively worsening pain and swelling in his right knee that started overnight.  The patient took two over-the-counter ibuprofen tablets earlier in the day, which were ineffective.  He was diagnosed with gout six months ago when he had an ankle effusion, and he was started on allopurinol at that time.  His other medical problems include recurrent renal stones, hypertension, and chronic rotator cuff tendinitis.  His home medications include benazepril and allopurinol 100 mg daily.
On examination, the right knee appears swollen and tender.
Laboratory studies show a white blood cell count of 12,200 cells/µL, serum creatinine of 1.1 mg/dL, uric acid level of 9 mg/dL (11 mg/dL 6 months ago), and normal liver function tests.  Knee aspiration reveals monosodium urate crystals.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_9922_b946_853d_435799ba861e_MD0002_00 This patient's presentation is consistent with an acute gouty attack, which is evident by the positive synovial fluid crystals. NSAIDs are the first-line treatment for acute gout. Since this patient has already taken ibuprofen, colchicine or corticosteroids (oral or intra-articular) can be used as an alternative therapy. Once the acute attack subsides, prevention of future attacks involves dietary and lifestyle changes (e.g., weight loss, decrease alcohol intake, discontinue diuretics). Patients with recurrent attacks after making appropriate lifestyle changes require pharmacotherapy for prophylaxis. Other indications for prophylaxis include nephrolithiasis, tophaceous gout, x-ray findings of gouty arthritis, or urinary uric acid excretion > 1100 mg/day. Allopurinol is preferred by most clinicians for prophylaxis, and prophylactic colchicine is frequently started at the same time to prevent acute gouty attacks. The allopurinol dose is increased until the patient's serum uric acid level is < 6 mg/dL. Prophylactic colchicine is usually given for 6 months after the uric acid level normalizes. Patients who develop an acute gouty attack while taking allopurinol should not stop the drug or have their dose adjusted, since this can worsen the acute attack (Choices B & D). The allopurinol dose may be adjusted 3-4 weeks after the acute inflammation subsides. (Choice C) Febuxostat is also a xanthine oxidase inhibitor that is usually reserved for patients who cannot tolerate allopurinol or have mild to moderate chronic kidney disease. This patient appears to be tolerating allopurinol and has normal kidney function. (Choice E) Intravenous pegloticase is a novel agent and a treatment option for patients who have chronic gout refractory to other available treatments. Educational objective: Acute gout is usually treated with NSAIDs as first-line therapy and colchicine as second-line therapy. Allopurinol is usually given for prophylaxis along with colchicine to patients with recurrent gout, tophaceous gout, nephrolithiasis, radiographic evidence of gouty arthritis, or urinary uric acid excretion > 1100 mg/day. Patients who develop a gouty attack while taking allopurinol should not undergo dose adjustments or drug discontinuation until 3-4 weeks after the acute inflammation subsides. __________ References: 2011 Recommendations for the diagnosis and management of gout and hyperuricemia. (http://www.ncbi.nlm.nih.gov/pubmed/22156509) Serum urate during acute gout. (http://www.ncbi.nlm.nih.gov/pubmed/19369457) Factors associated with acute gout attacks in normouricemic gout patients receiving allopurinol: a retrospective study. (http://www.ncbi.nlm.nih.gov/pubmed/21916803)

A 55-Year-Old Man with a History of Gout Comes to the Physician