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Introduction: Management of Acute Gout

Rob Orman, MD and Heidi James, MD
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17:54

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The podagra strikes again!

  • Pearls:

    • Low-dose colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapies for gout.

    • Steroids are an alternative to NSAIDs or colchicine and may be safer.

 

  • When evaluating a patient with classic podagra (a painful, red, swollen first metatarsophalangeal joint), Drs. Orman and James’ practice is to make a clinical diagnosis and not perform arthrocentesis.  They feel that aspiration of synovial fluid from this small joint is challenging and low yield, even in the most experienced hands.

  • Acute gout treatment

    • Colchicine

      • Although it was first recognized as effective for gout treatment in the 1700s, colchicine wasn’t evaluated in a clinical trial until 1987.  In this study, the patients who received colchicine had better and faster pain relief than those who received placebo.  All patients given colchicine, however, developed diarrhea, usually before relief of pain.  This study had limitations:  no patients received NSAIDs in the first 48 hours and the colchicine dose was very high.  Ahern M,  et al. "Does colchicine work? The results of the first controlled study in acute gout." Australian and New Zealand journal of medicine 17.3 (1987): 301-304. [PMID 3314832]

      • A more recent study comparing low- and high-dose colchicine found that the lower dose was just as effective at achieving pain relief, but with a safety profile similar to placebo.  At the lower dose, 1.2 mg of colchicine was given at onset of a flare, followed by 0.6 mg an hour later.  Terkeltaub R, et al. "High versus low dosing of oral colchicine for early acute gout flare: Twenty‐four–hour outcome of the first multicenter, randomized, double‐blind, placebo‐controlled, parallel‐group, dose‐comparison colchicine study." Arthritis & Rheumatism 62.4 (2010): 1060-1068. [PMID 20131255]

      • Since colchicine is known to have renal toxicity, is it necessary to check renal function before initiating therapy?  Probably not in low-risk patients.

    • NSAIDs

      • While indomethacin is widely regarded as the best NSAID for the treatment of acute gout, no study has found it (or any other NSAID) to be clearly superior to another in relieving the pain of gout.  When prescribing indomethacin, Dr. Orman starts at 50 mg tid, then has the patient reduce to 25 mg tid when symptoms start improving.  The dose is further tapered to 25 mg bid when the attack is nearly resolved.

      • Since gout progresses quickly, NSAID treatment should be started as soon as possible.

    • Glucocorticoids

      • Have been shown to work as well as NSAIDs.  Most treatment algorithms recommend oral steroids for patients who are unable to receive NSAID or colchicine therapy.  A tapering dose over about a week is generally recommended.

      • There is some evidence that glucocorticoids may be safer than NSAIDs.  Wechalekar M, et al. "The Efficacy and Safety of Treatments for Acute Gout: Results from a Series of Systematic Literature Reviews Including Cochrane Reviews on Intraarticular Glucocorticoids, Colchicine, Nonsteroidal Antiinflammatory Drugs, and Interleukin-1 Inhibitors." The Journal of Rheumatology 92 (2014): 15-25.  [PMID 25180124]

    • Narcotics

      • Although not mentioned in treatment algorithms, opioids may be necessary for severe pain while other remedies take effect.

Single versus combination therapy - a cornucopia of options!

  • Dr. Orman treats acute gouty arthritis with a tapering course of indomethacin and a single low-dose of colchicine.  He has a physician friend with gout who self-medicates with 100 mg of prednisone, 50 mg of indomethacin, and 1.2 mg of colchicine.  While seemingly effective, neither of these cocktails are based on published data.  

In one study, prednisone combined with paracetamol was equally effective to indomethacin combined with paracetamol.  Those receiving indomethacin had a higher rate of gastrointestinal bleeding (11% versus 0%) as well as a higher incidence of gastric pain (30% versus 0%).  Man C, et al. "Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial." Annals of emergency medicine 49.5 (2007): 670-677. [PMID 17276548]

Christine E. -

Another great episode! Are there any plans to provide review questions, like the ones available for EM:RAP episodes? I find this helps my retention. Thanks!
- A Family Resident from Canada

Rob O., MD -

Hi Christine! As of now, we are not doing board review type questions for Primary Care RAP. It's in our future planning though.

Christopher B. -

Hi guys-

Question for other practitioners out there: I have a colleague who, when he has a patient with a hot, red joint that he suspects is gout, will aspirate a DIFFERENT, non-problematic joint, stating these other joints are (1) easier to tap, (2) less painful to tap and (3) most importantly, would still show crystals if the patient is having a gout attack.
Anyone else do this? Any evidence behind it?

Thank you guys for this podcast - truly enjoy listening to it!

Chris
PA-C in Tillamook, OR

Rob O., MD -

Hey Chris!

First off, I am a big fan of Tillamook. We used to live in Portland and went to the coast/Tillamook/Manzanita quite a bit.

As far as tapping an asymptomatic joint, my first reaction was, "Madness! What kind of nonsense it this? If the joint is inflamed, why not go where the money is?" But then I did a lit search and found this article
http://annals.org/article.aspx?articleid=713103
that somewhat supports the non-inflamed joint arthrocentesis idea (although not the exact scenario in your question).

Christopher B. -

Interesting - so treat the gout, have the patient come back when their toe/knee is no longer bothering them, tap the formerly inflammed joint (which would now be less painful) and confirm your diagnosis.
If it's a classic presentation, I get the ease of simply making a clinical diagnosis. But there are always those patients who are atypical and the diagnosis isn't a slam dunk. You order the serum uric acid (knowing it really won't help rule in or out the diagnosis) and you are left really wanting to confirm the diagnosis by getting some joint fluid!

Appreciate the response.

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Strep Throat burns out the Gout! Full episode audio for MD edition 190:58 min - 90 MB - M4AHippo Primary Care RAP March 2015 Summary 430 KB - PDF

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