From the Guidelines
The most appropriate next step in managing this 64-year-old woman with acute gouty arthritis is to initiate colchicine therapy. Given her recent hemicolectomy, NSAIDs should be avoided due to the risk of bleeding and impaired wound healing, as suggested by the 2012 American College of Rheumatology guidelines for management of gout 1. Corticosteroids are another option, but colchicine is preferred initially due to its efficacy and relatively favorable side effect profile in the post-surgical setting. The diagnosis is confirmed by the presence of negatively birefringent crystals, which are characteristic of monosodium urate crystals seen in gout.
Some key points to consider in the management of acute gouty arthritis include:
- Initiating pharmacologic therapy within 24 hours of onset, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1
- Using colchicine, NSAIDs, or corticosteroids as first-line options for treatment, with certain combinations employed for severe or refractory attacks, as suggested by the 2012 American College of Rheumatology guidelines for management of gout 1
- Continuing established pharmacologic urate-lowering therapy (ULT) without interruption during an acute attack, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1
The patient should also receive appropriate pain management with acetaminophen and ice application to the affected joint. Adequate hydration should be maintained, and dietary modifications to reduce purine intake can be recommended. Once the acute attack resolves, consideration should be given to urate-lowering therapy such as allopurinol if this is a recurrent episode, but this should be initiated only after the acute inflammation has subsided, typically in 2-4 weeks, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. The patient should be monitored for potential side effects of colchicine, including gastrointestinal symptoms and, rarely, myelosuppression, especially important in a post-surgical patient.
It is also important to note that the 2016 updated EULAR evidence-based recommendations for the management of gout suggest that colchicine and NSAIDs should be avoided in patients with severe renal impairment, and that colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1. However, in this case, the patient's renal function is not mentioned as being impaired, and there is no mention of her receiving any medications that would interact with colchicine.
Overall, the management of acute gouty arthritis should be tailored to the individual patient's needs and medical history, with consideration given to the potential risks and benefits of different treatment options.
From the FDA Drug Label
Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis
The most appropriate next step in management is Indomethacin therapy. This is because indomethacin has been shown to be effective in relieving the symptoms of acute gouty arthritis, which is consistent with the patient's presentation of severe right great toe pain, warmth, and negatively birefringent crystals. 2
From the Research
Management of Acute Gouty Arthritis
The patient presents with severe right great toe pain, warmth, and negatively birefringent crystals, 3 days after a right hemicolectomy for cecal cancer, indicating acute gouty arthritis. The most appropriate next step in management is to treat the acute gouty arthritis.
Treatment Options
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferred treatment for acute gout, as they can effectively reduce inflammation and pain 3, 4, 5.
- Colchicine is also an effective treatment for acute gout, especially in patients who cannot tolerate NSAIDs 3, 4, 5, 6.
- Corticosteroids can be used to treat acute gout, especially in patients with contraindications to NSAIDs and colchicine 4, 5, 6.
Recommended Treatment
Based on the evidence, the most appropriate next step in management would be to initiate treatment with NSAIDs, such as indomethacin, or colchicine. Allopurinol therapy is not recommended for the treatment of acute gouty arthritis, as it is used for the prevention of recurrent gout 3, 4, 7. Methotrexate therapy is not typically used for the treatment of acute gouty arthritis. Incision and drainage may be considered if there is evidence of infection, but it is not the most appropriate next step in this case.
Best Course of Action
The best course of action would be to start the patient on indomethacin therapy (option C) or colchicine therapy (option B), as these are both effective treatments for acute gouty arthritis 3, 4, 5, 6.