A 55-year-old man comes to the emergency department with severe right foot pain that started suddenly in the middle of the night. He has never had such symptoms before. He has a history of diet-controlled type 2 diabetes mellitus. His BMI is 32 kg/m². Physical examination shows swelling and tenderness of the first metatarsophalangeal joint. His leukocyte count is 13,500/µL and serum creatinine is 0.8 mg/dL. Joint aspiration is performed, and synovial fluid microscopic findings are shown in the image below. Which of the following is the best initial treatment for this patient?

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11ec160b_3c7c_dcda_9249_cd91cc806e31_MD0001_00 Synovial fluid analysis in this patient with acute monoarthritis shows needle-shaped, negatively birefringent crystals (ie, monosodium urate crystals) under polarized light, which are diagnostic for gout. Phagocytosis of urate crystals by neutrophils causes the release of various cytokines and inflammatory mediators that lead to further neutrophil activation and chemotaxis, resulting in a positive feedback loop that amplifies the inflammatory response. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for most patients with acute gouty arthritis. They inhibit cyclooxygenase enzymes and therefore decrease prostaglandin synthesis and exert a broad anti-inflammatory effect that includes inhibition of neutrophils. NSAIDs should be avoided in patients with renal and hepatic dysfunction or those at high risk for peptic ulcer. (Choice B) Lipoxygenase inhibitors (eg, zileuton) decrease production of pro-inflammatory leukotrienes and are indicated for treatment of asthma. Lipoxygenase inhibitors are not useful in the treatment of acute or chronic gout. (Choice C) Glucocorticoid therapy, either systemic or intraarticular, is used in patients with contraindications to both NSAIDs and colchicine (eg, renal dysfunction, the elderly). In addition, this patient has diabetes mellitus, and glucocorticoid use will increase his blood glucose levels. (Choice D) Antibiotics are used in patients with acute septic arthritis. Synovial fluid analysis in septic arthritis will show bacteria and a high concentration of leukocytes. (Choice E) TNF-alpha inhibitors (eg, infliximab, etanercept) are used as disease-modifying agents in rheumatoid arthritis. (Choices F and G) Uric acid-lowering therapy with uricosuric agents (eg, probenecid) or xanthine oxidase inhibitors (eg, allopurinol, febuxostat) is used to prevent acute attacks in patients with recurrent and progressive gouty arthritis and those with macroscopic tophi. These drugs should not be initiated during an acute gout attack as they can exacerbate acute arthritis. Educational objective: Nonsteroidal anti-inflammatory drugs are the first-line treatment for acute gouty arthritis. They inhibit cyclooxygenase and therefore decrease prostaglandin synthesis and exert a broad anti-inflammatory effect that includes inhibition of neutrophils. __________ References: Treatment of acute gout: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/24650777)

A 55-Year-Old Man Comes to the Emergency Department with Severe