A 53-year-old man comes to the emergency department at 6:00 AM due to severe pain in his right great toe for the past 3 hours. His pain began suddenly as a dull ache, and rapidly worsened to severe throbbing that is not relieved by acetaminophen. Medical history is notable for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. The patient has smoked 2 packs of cigarettes daily for 30 years. He drinks 2-3 beers and 3-4 cups of coffee daily, consumes fast food often, and does not exercise regularly. Current medications include metformin, losartan, amlodipine, sitagliptin, and atorvastatin. The patient's temperature is 36.8 C (98.2 F), blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 16/min. On examination, the right great toe appears markedly swollen, red, and warm to the touch. Which of the following interventions would be most appropriate to prevent development of further similar episodes in this patient?

Question

A 53-year-old man comes to the emergency department at 6:00 AM due to severe pain in his right great toe for the past 3 hours.  His pain began suddenly as a dull ache, and rapidly worsened to severe throbbing that is not relieved by acetaminophen.  Medical history is notable for hypertension, type 2 diabetes mellitus, and hypercholesterolemia.  The patient has smoked 2 packs of cigarettes daily for 30 years.  He drinks 2-3 beers and 3-4 cups of coffee daily, consumes fast food often, and does not exercise regularly.  Current medications include metformin, losartan, amlodipine, sitagliptin, and atorvastatin.  The patient's temperature is 36.8 C (98.2 F), blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 16/min.  On examination, the right great toe appears markedly swollen, red, and warm to the touch.  Which of the following interventions would be most appropriate to prevent development of further similar episodes in this patient?

Quizplus · Accepted Answer

11ec25c8_d11b_a6e4_bc81_31a5fb548dc9_MD0003_00 This patient has sudden-onset severe pain in the first metatarsophalangeal joint (podagra) consistent with acute gout. Initial treatment can include nonsteroidal anti-inflammatory drugs (eg, indomethacin), glucocorticoids, or colchicine. Urate-lowering medications (eg, allopurinol, febuxostat) are indicated for patients with recurrent attacks or complicated disease (eg, tophi, uric acid kidney stones). This patient is having his first attack and does not require urate-lowering medication; however, he has multiple risk factors for recurrent gout (ie, obesity, hypertension, insulin resistance) and should be counseled on lifestyle modification to reduce his risk. Weight loss and caloric restriction can reduce the risk of recurrent gout. In addition, specific dietary changes are also recommended. The risk of attacks is increased with intake of red meat and seafood but is reduced in diets emphasizing protein from vegetarian and low-fat dairy sources. Risk is also increased by heavy intake of beverages and foods containing fructose and other refined sugars. Heavy alcohol intake, especially from beer and distilled spirits, is also associated with an increased risk of gout attack. Ethanol increases uric acid production and may also decrease renal elimination of uric acid. (Choices B and C) A number of medications, including thiazide and loop diuretics, aspirin, and beta blockers, can increase the risk of gouty attacks. Losartan and calcium channel blockers lower uric acid levels and likely reduce the risk of an attack. Atorvastatin and rosuvastatin also lower serum uric acid slightly. (Choice D) Glucocorticoids may be used for acute treatment of gout as well as short-term prevention of flare-ups in patients starting urate-lowering therapy. Otherwise, glucocorticoids are not recommended for routine gout prophylaxis and would be relatively contraindicated in patients with diabetes. (Choice E) Higher consumption of coffee (but not tea) is associated with lower uric acid levels and a decreased risk of gout attack. (Choice F) Smoking is associated with a lower risk of gout due to decreased endogenous production of uric acid. Educational objective: Lifestyle modifications, including alcohol cessation and weight loss, are recommended to prevent recurrent gout attacks. Medications for lowering serum urate are indicated for patients with repeated attacks of gouty arthritis or complicated disease (eg, tophi, uric acid kidney stones). References: Alcohol quantity and type on risk of recurrent gout attacks: An internet-based case-crossover study. (http://www.ncbi.nlm.nih.gov/pubmed/24440541)

A 53-Year-Old Man Comes to the Emergency Department at 6:00