9.10 Acute Gouty Arthritis
==========================

agk's Library of Common Simple Emergencies

Presentation
------------

Usually a male patient over 50 years old with 
an established diagnosis of gout or hyper- 
uricemia 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:
-----------

- If the patient has not been previously 
    diagnosed by arthocentesis that showed 
    crystals, then tap the involved joint as 
    described in [acute monarticular 
    arthritis]. In addition to ruling out 
    infection, look under the microscope for 
    crystals in the joint fluid. Urate crystals 
    look like needles, and may be in white 
    cells. Polarizing filters above and below 
    the sample can help disclose and 
    differentiate crystals.
- Provide rapid pain relief with loading doses 
    of non-steroidal anti-inflammatory drugs 
    (NSAIDs) such as ketorolac (Toradol) 60mg 
    im, indomethicin (Indocin) 50mg po, 
    ibuprofen (Motrin) 800mg po or naproxin 
    (Anaprox) 550mg po, then tapering, once 
    pain is relieved, to maintenance doses for 
    the next few days (Indocin 25mg tid or 
    Motrin 600mg qid). Excruciating pain may 
    require one dose of narcotics while the 
    anti-inflammatory drugs take effect.
- If the patient has a medical problem (e.g., 
    peptic ulcer or gastritis, liver or kidney 
    disease) which might contraindicate use of 
    the non-steroidal anti-inflammatory 
    medications or colchicine, but no infection 
    or uncontrolled diabetes or hypertension, 
    use parenteral, oral or intra-articular 
    corticosteroids, like triamcinolone 60mg im 
    or prednisone 40-50mg qd. Delay injecting 
    corticosteroids into the joint until the 
    possibility of infection is eliminated, 
    then use an aqueous suspension of methyl- 
    prednisolone, about 40mg in 0.5ml. Adreno- 
    corticotropic hormone (ACTH) 80 USP Units 
    IM is also effective in about three hours.
- Instruct the patient to elevate and rest the 
    painful extremity, apply ice packs, and 
    arrange for followup.

What not to do:
---------------

- Do not depend on serum uric acid to diagnose 
    acute gouty arthritis--it may or may not be 
    elevated (>8mg/dl) at the time of an acute 
    arthritis.
- Do not use NSAIDs when a patient has a 
    history of active peptic ulcer disease with 
    bleeding. Relative contraindications 
    include renal insufficiency, volume 
    depletion, gastritis, inflammatory bowel 
    disease, asthma and congestive heart 
    disease.
- Do not start maintenance NSAID doses for an 
    acute inflammation. It will take a day or 
    more to reach therapeutic levels and pain 
    relief.
- Do not insist upon re-confirming a diagnosis 
    of gout in the ED by ordering serum uric 
    acid levels (which are often normal during 
    the acute attack) or tapping an exquisitely 
    painful joint in a patient with known gout.
- Do not, during an acute attack of gouty 
    arthritis, attempt to reduce the serum uric 
    acid level with probenecid, allopurinol, or 
    sulfinpyrazone. This will not help the 
    arthritis, and may even be counterproduct- 
    ive. Leave it for follow up.

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 allo- 
purinol, 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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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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