Review Question - QID 103605

This patient is presenting with an acute flare of gout. Given his history of gastric ulcers, NSAIDs are contraindicated and colchicine is the most appropriate choice.

Acute gouty arthritis is caused by elevated levels of uric acid. This hyperuricemia is the result of excessive production or decreased renal excretion. A gout flare frequently occurs after years of asymptomatic hyperuricemia and typically involves a single joint - most often the first metatarsophalangeal joint or the knee. Treatment should begin as soon as possible following the onset of an attack. NSAIDS such as naproxen or indomethacin are first line agents for the reduction of inflammation during a gout flare. However, among patients with poor kidney function, active duodenal or gastric ulcer disease, cardiovascular disease, NSAID allergies, or current treatment with anticoagulants, NSAIDs are contraindicated. Colchicine is used among these patients. If colchicine is also contraindicated, an intra-articular steroid injection may be considered.

Eggebeen indicates that approximately 60% of people who have a gout attack will have another one within the next year. It is recommended that patients should start nonpharmacologic therapies to treat hyperuricemia. Specifically, modifiable risk factors such as decreasing red meat, seafood, and alcohol intake while increasing dairy intake should be suggested. Urate lowering drugs are recommended for patients with more than 2 gouty attacks per year, patients with tophi, and patients with joint damage seen on x-ray.

Richette and Bardin further discuss the management of chronic gout in their review. Urate lowering therapy should begin 1-2 weeks after the resolution of an acute attack, in order to lower the risk of another acute attack. During the first 3-6 months of urate lowering therapy, the use of NSAIDs or colchicine is also recommended to further reduce the risk of another flare. Allopurinol is the most commonly used urate lowering agent. The dose should be increased until target levels of uric acid are reached or the patient has reached the maximum allowed dose.

Illustration A demonstrates negatively birefringent urate crystals in the joint aspiration fluid of a patient with acute gouty arthritis. Note the yellow color of the needle-shaped crystals. Illustration B demonstrates the typical appearance of a joint affected by acute gouty arthritis. Note the swollen, red appearance.

Incorrect Answers:
Answer 1: This patient's history of gastric ulcers causes NSAIDs such as naproxen to be contraindicated.
Answer 3: While it is important to rule out the presence of septic arthritis, this patient's joint aspiration rules out infection, making antibiotics unnecessary.
Answer 4: Allopurinol and other urate lowering agents such as probenecid are not indicated during an acute gouty attack, and may worsen symptoms.
Answer 5: A steroid injection may be considered in this patient. However, since he has poor glycemic control colchicine is the most appropriate choice.