A 40-year-old obese man presents with intense pain in his left first metatarsophalangeal (MTP) joint for the past few hours. He has no history of trauma, fever, chills, and no previous similar episode. He has no history of renal disease or diabetes though he has been told he is "prediabetic." He does not recall any recent skin infections and no family members have had any reported staphylococcal infection. On examination he has a swollen, red, warm, tender first MTP joint on the left. Uric acid level is 9 mg/dL; serum creatinine is normal. What is the best treatment approach for this patient?
This patient is experiencing his first episode of acute gout. The first MTP joint is the most commonly affected, and 80% of acute gout attacks will be monoarticular. Predisposing conditions include trauma, surgery, starvation, high intake of beer and hard liquor (not wine), or diets high in meat and seafood. Certain medications also increase the chances of acute gout including thiazide and loop diuretics and even the initiation of uric acid lowering drugs such as allopurinol and uricosuric agents. Appropriate initial treatment must be tailored to the patient and their comorbidities. The patient in this question has no contraindication, so a potent NSAID (indomethacin) can be used and is likely to be highly effective. Other acceptable alternatives would have been to start colchicine immediately or oral prednisone in relatively high doses. Since this patient is "prediabetic," steroids may result in overt hyperglycemia and hence would not be the first choice. Allopurinol should not be started until the acute attack has been controlled by anti-inflammatory regimens. All agents that lower uric acid levels (either allopurinol or uricosuric agents) can cause worsening of joint pain, probably by mobilizing uric acid microcrystals previously deposited in the synovial membrane. While narcotics may lessen the pain, they are less effective than anti-inflammatories. Referring the patient to a rheumatologist is unnecessary and would leave the patient in pain and suffering in the meantime.
Start allopurinol immediately and titrate for a uric acid level below 6. Add colchicine if this is not effective within the first 24 hours.
Begin prednisone until symptoms subside.
Begin indomethacin. As the patient improves, reduce the dose to minimize gastrointestinal side effects.
Prescribe a narcotic until pain is under control.
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