How to diagnose and manage a suspected gout flare in a patient presenting with foot pain?

Diagnosis and Management of Suspected Gout Flare in a Patient with Foot Pain

For a patient presenting with foot pain and suspected gout, synovial fluid analysis is the gold standard diagnostic test, but when this is not feasible, a clinical diagnosis can be made based on characteristic features including monoarticular involvement of the foot, previous similar episodes, rapid onset of severe pain, and presence of hyperuricemia. 1

Diagnostic Approach

Step 1: Clinical Assessment

• Consider gout in the diagnosis of any acute arthritis in an adult, especially with foot involvement 1
• Look for suggestive clinical features:
  • Monoarticular involvement of a foot (especially the first metatarsophalangeal joint) or ankle joint 1
  • Previous similar acute arthritis episodes 1
  • Rapid onset of severe pain and swelling (reaching maximum intensity within 24 hours) 1
  • Erythema over the affected joint 1
  • Male gender and associated cardiovascular diseases 1
  • Hyperuricemia (though this alone is insufficient for diagnosis) 1

Step 2: Diagnostic Testing

• Synovial fluid analysis is the definitive test for gout diagnosis through identification of monosodium urate (MSU) crystals 1
• When synovial fluid analysis is not feasible:
  • Serum uric acid testing can be helpful but should not be the sole basis for diagnosis 1
  • Note that hyperuricemia alone is insufficient to diagnose gout, as many people with elevated uric acid levels never develop gout 1

Step 3: Imaging (when diagnosis is uncertain)

• Ultrasound is preferred for suspected gout flares - can detect tophi not evident on clinical examination or double contour sign at cartilage surfaces 1
• Plain radiographs have limited value for diagnosing acute gout flares but may help identify chronic changes 1

Management of Acute Gout Flare

First-line Treatments

• Nonsteroidal anti-inflammatory drugs (NSAIDs) - effective for pain relief in acute gout episodes 2, 3
• Colchicine - particularly effective when started early in the course of an acute attack 4, 2
• Corticosteroids - can be used when NSAIDs or colchicine are contraindicated 2, 5

Important Considerations for Treatment

• For patients with renal impairment, colchicine dosing may need adjustment 4
• For patients with severe renal failure (CrCl less than 30 mL/min), colchicine should be used with caution and at reduced doses 4
• Treatment should be initiated as early as possible after symptom onset for maximum effectiveness 2

Risk Factor Assessment and Modification

• Search for risk factors for chronic hyperuricemia in every person with gout 1:

  • Chronic kidney disease 1
  • Overweight/obesity 1
  • Medications (including diuretics, low-dose aspirin, cyclosporine, tacrolimus) 1
  • Consumption of excess alcohol (particularly beer and spirits) 1
  • Non-diet sodas, meat (especially organ meats) and shellfish 1, 2

• Systematically assess for associated comorbidities 1:

  • Obesity, renal impairment, hypertension 1
  • Ischemic heart disease, heart failure 1
  • Diabetes and dyslipidemia 1

Patient Education and Self-Management

• Advise the patient to:
  • Limit consumption of purine-rich foods (organ meats, shellfish) 2
  • Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 2
  • Increase consumption of vegetables and low-fat dairy products 2
  • Maintain adequate hydration 5

Follow-up Recommendations

• If this is the first gout attack, address modifiable risk factors 5
• For recurrent attacks (≥2 per year), consider urate-lowering therapy 3
• Monitor serum uric acid levels to guide long-term management 2

Common Pitfalls to Avoid

• Do not rely solely on serum uric acid levels for diagnosis, as normal levels can be present during acute attacks 1
• Do not miss septic arthritis - if there is suspicion, joint aspiration is essential 1
• Epsom salts and foot soaks may provide symptomatic relief but are not evidence-based treatments for gout 1
• Do not delay treatment of acute attacks - early intervention leads to better outcomes 2, 5