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9.10 Acute Gouty Arthritis


Presentation

Usually a male patient over 50 years old with an established diagnosis of gout or hyperuricemia rapidly develops an intensely painful monarticular arthritis, often in the middle of the night, but sometimes a few hours following a minor trauma. Any joint may be affected, but most common is the metatarsophalangeal joint of the great toe (podagra). The joint is red, hot, swollen, and intensely tender to touch or movement. There is usually no fever, rash, or other sign of systemic illness. The patient may have predisposing factors that increase his risk of developing gout, like obesity, moderate to heavy alcohol intake, high blood pressure, diabetes and abnormal kidney function, or he may be taking certan drugs including thiazide diuretics, low-dose aspirin, and tuberculosis medications (pyrazinamide and ethambutol).

What to do:

What not to do:

Discussion

Gout is almost exclusively a disease of adult men and is rare in premenopausal women and prepubertal children. While hyperuricemia may indicate an increased risk of gout, the relationship between serum uric acid and arthritis is unclear. Many patients with hyperuricemia do not develop gout, while some patients with repeated gout attacks have normal or low uric acid levels. In addition to the first metatarsophalahgeal joint involved in podagra, gout can strike ankles, knees, wrists, fingers and elbows. These painful attacks usually subside in hours to days with or without treatment. Most patients with gout experience repeated attacks of arthritis over the years. Conditions other than septic arthritis that can mimic gout include psoriatic arthritis, rheumatoid arthritis and pseudogout (in which crystals of calcium oxalate replace uric acid).

Uric-acid-lowering medications like allopurinol, probenecid or sulfinpyrazone are useful for prophylaxis but can actually worsen an attack when used acutely. If patients are already taking maintenance doses, they may be continued and need not be held during an acute attack. An alternative treatment for acute gouty arthritis is colchicine po 1-2mg qh until pain is relieved, the patient develops nausea, vomiting or diarrhea, or a maximum dose of 6mg is reached. Colchicine can also be given iv 2mg q6h to a maximum of 4mg. After these maximum doses, no more colchicine should be prescribed for a week to avoid toxicity. Relief is faster with intravenous administration and gastric toxicity is lower, but heptic toxicity is greater and extravasation can cause tissue necrosis. These doses should be halved in renal insufficiency and elderly patients. Colchicine may also be used for prophylaxis in the smaller dose of 0.6mg po qd, especially in the first few months of treatment with allopurinol, probenecid or sulfinpyrazone, which lower uric acid but can initially precipitate attacks.


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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD