What is the recommended analgesic for acute monoarticular arthritis (inflammation of a single joint) of the first metatarsophalangeal joint (joint of the great toe)?

Management of Acute Pain in the Great Toe Joint

For acute sticking pain in the first metatarsophalangeal joint (great toe joint), paracetamol (acetaminophen) is the recommended first-line oral analgesic due to its favorable efficacy and safety profile. 1

First-Line Treatment Approach

Oral Analgesics

• Paracetamol (Acetaminophen)
  • Initial dose: Up to 4g/day divided into 4 doses 1
  • Benefits: Good safety profile with minimal side effects
  • Duration: Can be used for short-term pain management and as long-term analgesic if effective 1

If Pain Persists or is Moderate-Severe

• NSAIDs (oral or topical) should be considered when:
  • Paracetamol provides inadequate relief 1
  • Inflammation is present (swelling, redness)
  • Pain is moderate to severe (>5/10 on pain scale)

Treatment Algorithm Based on Clinical Presentation

For Suspected Gout (Acute Monoarticular Arthritis)

1. Low-dose colchicine (1.2mg followed by 0.6mg one hour later for total dose of 1.8mg) 2

   • Most effective when started within 12-24 hours of symptom onset
   • Shown to provide significant pain reduction within 24 hours compared to placebo

2. NSAIDs (if colchicine is contraindicated or unavailable)

   • Full anti-inflammatory dosing 1
   • Options include naproxen, indomethacin, or sulindac 1

For Osteoarthritis of the First MTP Joint

1. Paracetamol (first-line)

2. Topical NSAIDs (second-line) 1

   • Particularly effective when only one or few joints are affected
   • Good safety profile compared to oral NSAIDs

3. Oral NSAIDs (if above treatments fail) 1

   • Use lowest effective dose for shortest duration
   • For patients with increased GI risk (age ≥60, history of peptic ulcer):
     • Consider gastroprotective agent with non-selective NSAID
     • Or use COX-2 selective inhibitor (with caution in patients with cardiovascular risk) 1

Special Considerations

Risk Assessment Before NSAID Use

• GI Risk Factors: Age ≥60, comorbidities, history of peptic ulcer/GI bleeding, concurrent corticosteroid or anticoagulant use 1
• CV Risk Factors: Hypertension, history of heart disease, cerebrovascular disease
• Renal Function: Assess before prescribing NSAIDs, especially in elderly patients

Pitfalls to Avoid

1. Misdiagnosis: Acute pain in the first MTP joint could indicate various conditions:

   • Gout (most common) 3
   • Septic arthritis (medical emergency requiring joint aspiration) 3
   • Osteoarthritis
   • Trauma
   • Rarely, manifestation of systemic disease 4

2. Delayed Treatment: For suspected gout, early treatment (within 24 hours) leads to better outcomes 1

3. Overuse of NSAIDs: Despite being more effective than paracetamol for joint pain 5, NSAIDs carry higher risks of adverse effects and should be used at lowest effective dose for shortest duration 1

Follow-up Recommendations

• Re-evaluate response to treatment within 1-2 weeks
• If symptoms persist despite appropriate analgesic therapy, consider:
  • Diagnostic joint aspiration to rule out infection or confirm crystal arthropathy
  • Imaging studies to assess joint damage
  • Referral to rheumatology or podiatry for specialized management

The evidence strongly supports starting with paracetamol for most patients with acute great toe pain, progressing to NSAIDs or specific treatments like colchicine if the initial approach fails or if specific diagnoses like gout are suspected.