What is the treatment for metatarsal gout?

Treatment for Metatarsal Gout

The treatment of metatarsal gout requires both pharmacological and non-pharmacological approaches tailored to the specific clinical phase (acute attack vs. chronic management) and should include NSAIDs, colchicine, or corticosteroids for acute attacks, followed by urate-lowering therapy for long-term management in patients with recurrent attacks. 1, 2

Acute Gout Attack Management

First-Line Treatments

• Oral colchicine and/or NSAIDs are first-line agents for systemic treatment of acute attacks 2
• Treatment should begin within 24 hours of symptom onset for optimal effectiveness 1
• Low-dose colchicine regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1
  • High doses lead to significant gastrointestinal side effects; low doses (0.5 mg three times daily) may be sufficient 2
  • Most effective when started within 12 hours of symptom onset 1
• NSAIDs: Start at full anti-inflammatory doses
  • Caution in patients with renal impairment, history of peptic ulcer disease, or cardiovascular disease 1

Alternative Options

• Intra-articular aspiration and injection of long-acting steroid is an effective and safe treatment for an acute metatarsal gout attack 2
• Systemic corticosteroids are equally effective as NSAIDs for pain relief 1
• Combination therapy may be considered for severe or refractory attacks 1

Important Adjuncts

• Rest and ice application to the affected metatarsal joint 1
• Continue established urate-lowering therapy during acute attacks 1

Long-Term Management

Indications for Urate-Lowering Therapy (ULT)

ULT is indicated in patients with:

• Recurrent acute attacks
• Arthropathy
• Tophi
• Radiographic changes of gout 2

Urate-Lowering Medications

• Allopurinol is the appropriate first-line urate-lowering drug 2

  • Start at a low dose (100 mg daily)
  • Increase by 100 mg every 2–4 weeks if required
  • Adjust dose in patients with renal impairment
  • Target serum uric acid level below 360 μmol/L (6 mg/dL) 2

• Alternative options if allopurinol is not tolerated:

  • Febuxostat (equally effective but associated with abdominal pain, diarrhea) 1, 3
  • Uricosuric agents (probenecid, sulphinpyrazone) for patients with normal renal function 2
  • Benzbromarone for patients with mild to moderate renal insufficiency (risk of hepatotoxicity) 2

Prophylaxis During ULT Initiation

• Prophylaxis against acute attacks during the first months of urate-lowering therapy:
  • Colchicine (0.5–1 mg daily) and/or an NSAID (with gastroprotection if indicated) 2
  • Continue prophylaxis for at least 3-6 months after reaching target uric acid levels 3

Lifestyle Modifications

• Weight loss if obese 2, 1
• Dietary modifications:
  • Limit alcohol consumption (especially beer) 2, 1
  • Reduce intake of purine-rich foods (organ meats, shellfish) 3
  • Avoid beverages sweetened with high-fructose corn syrup 3
  • Encourage consumption of vegetables and low-fat dairy products 3
• Adequate hydration of at least 2 liters daily 1
• Regular moderate physical activity 1

Management of Comorbidities

• Address associated conditions such as hyperlipidemia, hypertension, hyperglycemia, and obesity 2
• If gout is associated with diuretic therapy, consider stopping the diuretic if possible 2
• For hypertension, consider losartan (has uricosuric effects) 2, 1
• For hyperlipidemia, consider fenofibrate (has modest uricosuric effects) 2

Common Pitfalls and Caveats

• Do not initiate ULT during an acute flare - wait until resolution of the flare 1
• Check for drug interactions with colchicine, especially P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole) 1
• Assess renal function before initiating colchicine - avoid in eGFR < 30 ml/min, reduce dose in eGFR 30-60 ml/min 1
• Monitor for allopurinol toxicity - skin rash may indicate serious adverse reaction 2
• NSAIDs increase risk of gastrointestinal bleeding and cardiovascular events - use with caution in at-risk patients 1

By following this comprehensive approach to treating metatarsal gout, focusing on both acute management and long-term prevention, patients can achieve effective symptom control and prevent recurrent attacks.