What is the best approach to manage left leg pain in a patient with a history of gout, currently taking Levothyroxine?

Management of Left Leg Pain in a Patient with History of Gout on Levothyroxine

For a 42-year-old male patient with left leg pain and history of gout who is currently taking levothyroxine, the recommended first-line treatment is NSAIDs, oral colchicine, or oral glucocorticoids, with the choice based on patient-specific factors and comorbidities. 1

Acute Pain Management Assessment

When evaluating left leg pain in a patient with gout history:

• Determine if this is an acute gout flare:

  • Look for typical signs: sudden onset, severe pain, redness, warmth, swelling
  • Most common locations: first metatarsophalangeal joint, ankle, midfoot, knee
  • Confirm with serum uric acid level (requested in lab work)

• If gout flare is suspected:

  • First-line therapy options 1, 2:
    1. Low-dose colchicine: 1.2 mg initially, followed by 0.6 mg one hour later
    2. NSAIDs: Naproxen 500 mg twice daily or ibuprofen 800 mg three times daily
    3. Oral glucocorticoids: Prednisone 30-35 mg daily for 3-5 days

• Adjunctive measures:

  • Topical ice application can provide additional relief 1, 2
  • Voltaren cream (diclofenac) as prescribed is appropriate for local pain relief

Considerations with Levothyroxine

• Thyroid function should be monitored (appropriate to request Thyroid Comprehensive panel) 3
• Levothyroxine does not directly contraindicate any gout medications
• Ensure proper levothyroxine administration (taken ≥30 minutes before eating) to maximize effectiveness 3

Duloxetine Consideration

• The trial of Duloxetine 30 mg QPM may be helpful if:
  • Pain has neuropathic components
  • Pain is chronic and not responding to other treatments
  • However, it is not a first-line treatment for acute gout pain 1, 2

Laboratory Monitoring

The ordered tests are appropriate:

• Uric acid level: Essential for gout management
• CBC and CMP: Important to assess kidney function before NSAID use
• Thyroid comprehensive panel: Appropriate for monitoring levothyroxine therapy

Long-term Management

If recurrent gout attacks are confirmed:

1. Lifestyle modifications 1, 2:

   • Limit alcohol intake, especially beer
   • Limit purine-rich foods
   • Limit high-fructose corn syrup
   • Weight loss program if overweight/obese

2. Consider urate-lowering therapy (ULT) if:

   • Patient has recurrent attacks (≥2 per year)
   • Tophaceous gout is present
   • Chronic kidney disease or urolithiasis is present 1, 2

3. ULT options:

   • Allopurinol: First-line, start at ≤100 mg/day, titrate to target uric acid <6 mg/dL 2
   • Always provide prophylaxis when starting ULT (colchicine, low-dose NSAIDs, or prednisone) 2

Common Pitfalls to Avoid

• Delaying treatment of acute flares (should start within 24 hours)
• Using high-dose colchicine (associated with more adverse effects) 1
• Starting ULT during an acute attack without appropriate prophylaxis
• Overlooking renal function when prescribing NSAIDs or colchicine
• Failing to address lifestyle factors that contribute to gout 2

The current management plan with Tylenol, Voltaren cream, and laboratory monitoring is reasonable, but if this is an acute gout flare, consider adding a more specific anti-inflammatory treatment such as low-dose colchicine, NSAIDs, or a short course of oral prednisone based on the patient's comorbidities and preferences.