Review Question - QID 103124

This patient is suffering from acute gouty arthritis given his great toe pain and negatively birefringent crystals on arthrocentesis. Intraarticular steroid injection is the preferred treatment of gout in patients with renal failure with disease limited to 1 or 2 joints.

Gout typically presents in overweight men with risk factors such as alcohol use, a diet high in meat, and decreased renal function. After a patient's first acute gout flare, management should include NSAIDs (when there are no contraindications such as renal failure or gastrointestinal disease) and lifestyle changes (weight loss and alcohol cessation). Treatment of acute gout should be initiated as soon as possible after the acute flare, preferably within several hours of symptom onset. Chronic gout medications such as allopurinol and other urate lowering drugs, are not effective in the treatment of acute gout and should not be initiated; however, patients already taking these agents should continue them without interruption during their acute gout flare and associated treatment. In patients with impaired kidney function with disease limited to 1 or 2 joints, intraarticular steroids are an appropriate treatment with minimal systemic effects. Other treatments could include agents such as rasburicase, which breaks down uric acid.

Figure A shows needle-shaped, negatively-birefringent monosodium urate crystals on polarized light microscopy that are consistent with a diagnosis of gout.

Incorrect Answers:
Answer 1: Aspirin is not used to treat acute gout flares due to its paradoxical effect on serum urate levels. NSAIDs are preferred including ibuprofen and indomethacin for patients who can tolerate them.

Answer 2: Colchicine is contraindicated in patients with renal or hepatic failure due to the risk of developing colchicine toxicity since it is cleared by the liver/kidneys. It is possible to lower the dose and adjust for renal function; however, in this patient with disease limited to 1 joint, an intraarticular injection will control symptoms and have minimal systemic effects.

Answer 3: Indomethacin (along with other NSAIDs) is contraindicated in patients with impaired kidney function. NSAIDs impair prostaglandin production which is needed for afferent arteriole dilation to maintain GFR. Given this patient's severely impaired kidney function, NSAIDs should be avoided.

Answer 5: IV prednisone or systemic steroids are not preferred in this patient given his poorly managed diabetes and hyperglycemia. Similarly, his symptoms are limited to 1 joint so systemic administration is not indicated.

Bullet Summary:
Intraarticular steroids are appropriate management of gout limited to only a few joints in patients who cannot tolerate NSAIDs or colchicine.