Review Question - QID 108564

This patient is presenting with classic symptoms of a gout flare for which the first line treatment is colchicine or NSAIDs. Colchicine acts to decrease neutrophil motility by inhibiting microtubule polymerization through tubulin binding; it is the best choice in this patient with an increased risk of bleeding due to known peptic ulcer disease.

Gout is an inflammatory arthritis that most commonly occurs in the great toe (podagra), causing a red, swollen, hot, and tender joint. Middle-aged and elderly men are most affected. It is associated with metabolic syndrome and can be precipitated by alcohol use, thiazides, and niacin. As in this patient, gout may flare in times of acute illness or surgery. Although not infectious, gout can cause an elevation in WBC as well as fever. Diagnosis of gout is often clinical, but arthrocentesis may be performed to confirm the diagnosis. Negatively birefringent (yellow when parallel to the light source) needle-shaped crystals are typically seen (Illustration A). Prophylaxis against future flares can be achieved with allopurinol, febuxostat, or probenecid, but these should only be started after the acute episode is resolved due to concern for worsening of immediate symptoms. Of note, this patient's hip pain is unlikely to be gout, as this disease rarely affects large joints and is usually not symmetric. This symptom is likely attributable to osteoarthritis.

Figure A shows a radiograph of a foot with podagra. At the first metatarsal-phalangeal joint, there are well-defined “punched-out” erosions ("rat-bitten" lesions) with sclerotic margins as well as an accompanying joint effusion. There is relative preservation of the joint space. These features are characteristic of gout. Illustration A demonstrates classic gout crystals - needle shaped and negatively birefringent (yellow when parallel to the light source).

Incorrect Answers:
Answer 1: Allopurinol inhibits xanthine oxidase and is used for prevention of gout flares. It is an analog of hypoxanthine and decreases uric acid formation. It does not relieve acute flares and may even worsen symptoms acutely.

Answer 2: Nonselective NSAIDs inhibit COX-1 and COX-2 in the arachidonic acid pathway. They ultimately decrease prostaglandin formation, producing an anti-inflammatory effect. They are considered first-line for acute gout flares if the patient does not have any contraindications. Common contraindications to NSAIDs include renal insufficiency/failure and gastrointestinal bleeding.

Answer 3: Probenecid acts by interfering with the kidneys’ organic anion transporter, which causes uric acid to be reabsorbed and thus increases urinary excretion of uric acid. It is therefore especially useful in patients whose gout is felt to be due to underexcretion (as opposed to overproduction) of uric acid. Probenecid should be reserved for chronic prophylaxis, not treatment of an acute flare.

Answer 4: Glucocorticoids act on downstream inflammatory gene expression and can be used either orally or intra-articularly for acute gout if NSAIDs are contraindicated or not tolerated. It is generally second line to colchicine for these cases and should not be used if there is concern for concurrent joint infection.

Bullet Summary:
Treatment of acute gout flares includes NSAIDs, colchicine, or steroids. Agents such as allopurinol, febuxostat, and probenecid are better suited for chronic management and prophylaxis against future flares.