A 50-year-old obese man comes to the emergency department with toe pain. He awoke this morning with sudden severe pain in his left great toe. He has never had this type of pain before and has had no trauma to the toe. The patient has a history of hypertension treated with hydrochlorothiazide. He also has osteoarthritis in his right knee that was treated with an intraarticular steroid injection 6 months ago. He smokes a pack of cigarettes and drinks 1 or 2 glasses of wine daily. His temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min. The patient's left great toe is inflamed, with swelling and erythema at the metatarsophalangeal joint. There is pain with minimal range of motion. There are no skin rashes. The remainder of the examination is within normal limits. The diagnosis of acute gout is made. Which of the following is the preferred treatment for the patient at this time?

Question

A 50-year-old obese man comes to the emergency department with toe pain.  He awoke this morning with sudden severe pain in his left great toe.  He has never had this type of pain before and has had no trauma to the toe.  The patient has a history of hypertension treated with hydrochlorothiazide.  He also has osteoarthritis in his right knee that was treated with an intraarticular steroid injection 6 months ago.  He smokes a pack of cigarettes and drinks 1 or 2 glasses of wine daily.  His temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min.  The patient's left great toe is inflamed, with swelling and erythema at the metatarsophalangeal joint.  There is pain with minimal range of motion.  There are no skin rashes.  The remainder of the examination is within normal limits. The diagnosis of acute gout is made.  Which of the following is the preferred treatment for the patient at this time?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0b1_7bae_8f63_ef84380b8bb0_MD0005_00 Treatment of acute gout is based on the patient's comorbidities, effectiveness of previous treatments, and patient preferences. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy and are effective in >90% of patients with acute gout. Nonselective agents with a short half-life (eg, indomethacin, ibuprofen) are usually preferred as they are inexpensive and effective in most patients. COX-2 inhibitors are also used as alternate therapy in some patients. Patients should continue the drug until 1-2 days after symptom resolution (a total of 5-7 days in most cases). Oral colchicine, an alternate therapy in patients with contraindications to NSAIDs, is used in acute or chronic kidney disease, heart failure, or peptic ulcer disease, or in those currently taking anticoagulation (Choice C). Colchicine is most effective if given within 24 hours of symptom onset. The drug is given as an initial 1.2-mg dose followed by 0.6 mg an hour later. Colchicine can then be continued at 0.6 mg once or twice daily until 2-3 days after symptoms resolve. However, the drug should be given at a reduced dose in the elderly. Colchicine is usually avoided in severe liver or renal disease and in patients taking another cytochrome P450 inhibitor. (Choice A) Hypouricemic therapy with allopurinol is avoided initially as it can worsen the acute gouty attack. Allopurinol is usually given after symptom resolution to prevent future acute gouty attacks in patients with recurrent episodes. (Choice B) Aspirin is generally not used for acute gout due to its effect on renal handling of uric acid. Low-dose aspirin (1-2 g/day) causes uric acid retention; high-dose aspirin (>3 g/day) leads to uricosuria. (Choice E) Intraarticular steroids can be used in acute gout for patients with one or two inflamed joints and contraindications to NSAIDs or colchicine. In addition, steroids are usually given after definitively diagnosing gout by arthrocentesis. Oral or intramuscular steroids are reserved for patients who cannot take NSAIDs, colchicine, or intraarticular steroids. Educational objective: Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy and are effective in >90% of patients with acute gout. Oral colchicine is an alternate therapy in patients with contraindications to NSAIDs. Intraarticular steroids can be used in acute gout for patients with one or two inflamed joints and contraindications to NSAIDs or colchicine. References: Diagnosis and treatment of gout in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/22272526)

A 50-Year-Old Obese Man Comes to the Emergency Department with Toe