A 36-year-old man comes to the emergency department due to acute pain in his left foot. He was previously feeling well but suddenly woke from sleep with severe pain at the base of his great toe. The patient has type 1 diabetes mellitus complicated by peripheral sensory neuropathy and proliferative retinopathy. He also has end-stage renal disease due to diabetic nephropathy, for which he underwent cadaveric renal transplant 18 months ago. The patient's diabetes is controlled by an insulin pump. His other medications include lisinopril, amlodipine, cyclosporine, mycophenolate, and prednisone (5 mg/day). Temperature is 37.3 C (99.1 F), blood pressure is 126/84 mm Hg, and pulse is 88/min. Physical examination shows an erythematous, swollen, warm, and tender left first metatarsophalangeal joint. Range of motion testing is limited by severe pain. There is a moderate hammertoe deformity at the third toe but no abnormal calluses. Posterior tibial and dorsalis pedis pulses are easily palpable. Bedside capillary glucose is 184 mg/dL. Examination of joint aspirate confirms the presence of crystals. Leukocyte count in the synovial fluid is 30,000/mm³. Gram stain is negative for organisms. Which of the following is the most appropriate drug for management of acute monoarthritis in this patient?

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Quizplus · Accepted Answer

Explanation: The management of acute gout is challenging in patients with renal failure or in those who have undergone renal transplant as nonsteroidal anti-inflammatory drugs (eg, indomethacin), which are the usual first-line treatment, are relatively contraindicated (Choice C). Low-dose colchicine (eg, renal dose adjustment) is usually effective; however, concurrent use of cyclosporine can cause delayed clearance of colchicine, leading to increased toxicity (eg, myoneuropathy). Additional options for the management of acute gout include systemic and intra-articular glucocorticoids. Because many patients receive glucocorticoids as part of their anti-rejection regimen, a temporary increase in the dose is a convenient way to terminate an acute gout flare and is especially useful for polyarticular gout. However, systemic glucocorticoids are associated with significant adverse effects, and intra-articular glucocorticoids (eg, triamcinolone) are better tolerated for those with monoarticular symptoms and would be most appropriate for this patient. (Choices A, B, and E) Urate-lowering therapy with either a xanthine oxidase inhibitor (eg, allopurinol, febuxostat) or a uricosuric agent (eg, probenecid) can be considered for patients with gouty arthritis following renal transplant. However, these agents should not be initiated until the acute attack has been fully treated; they can be continued in those who were taking them prior to the flare. If a patient is taking azathioprine (sometimes used following organ transplant), care should be taken when prescribing xanthine oxidase inhibitors because these agents can impair the metabolism of azathioprine. Educational objective: Treatment options for acute gout in patients with a history of renal transplant include low-dose colchicine and systemic and intra-articular glucocorticoids. Cyclosporine can cause delayed clearance of colchicine, leading to increased toxicity. References: Colchicine-induced myoneuropathy in a cyclosporine-treated renal transplant recipient. (http://www.ncbi.nlm.nih.gov/pubmed/26877917)

A 36-Year-Old Man Comes to the Emergency Department Due to Acute