Should a patient with gout and a persistently swollen shoulder receive an injection?

Management of Gout with Persistently Swollen Shoulder

Intra-articular glucocorticoid injection is strongly recommended for a persistently swollen shoulder in a patient with gout as it provides rapid pain relief and reduces inflammation. 1, 2

First-Line Treatment Options for Gout Flares

• Glucocorticoids (including intra-articular injections) are strongly recommended as first-line therapy for gout flares, along with oral colchicine and NSAIDs 1
• The American College of Rheumatology (ACR) 2020 guidelines specifically support intra-articular glucocorticoid injections as an appropriate first-line therapy for gout flares 1
• The FDA label for triamcinolone acetonide specifically indicates its use for intra-articular administration as adjunctive therapy for acute gouty arthritis 2

Benefits of Intra-articular Injection for Persistently Swollen Shoulder

• Intra-articular injections provide targeted therapy directly to the affected joint, which is particularly beneficial for a persistently swollen joint that hasn't responded to other treatments 2
• Local administration minimizes systemic side effects compared to oral glucocorticoids 1, 2
• Rapid onset of action provides quick relief of pain and inflammation 3
• Particularly useful when the patient has contraindications to oral therapies such as NSAIDs or colchicine 1

Practical Considerations for Injection

• Arthrocentesis prior to injection allows for:
  • Confirmation of diagnosis through synovial fluid analysis for monosodium urate crystals 4
  • Exclusion of septic arthritis, which is an important differential diagnosis 4
• Triamcinolone acetonide is commonly used for intra-articular injections in gouty arthritis 2
• The procedure should be performed using sterile technique to minimize infection risk 3

Comprehensive Management Approach

• While addressing the acute swollen joint with injection, also consider:
  • Initiating or optimizing urate-lowering therapy (ULT) if the patient has:
    • Frequent gout flares (≥2/year) 1
    • Presence of tophi 1
    • Radiographic damage attributable to gout 1
  • Allopurinol is strongly recommended as the preferred first-line ULT agent 1, 5
  • Concomitant anti-inflammatory prophylaxis should be provided when initiating ULT to prevent flares 1, 5

Adjunctive Measures

• Topical ice application is conditionally recommended as an adjuvant treatment for gout flares 1
• Lifestyle modifications should be addressed:
  • Limiting alcohol intake 1
  • Limiting purine-rich foods 1
  • Limiting high-fructose corn syrup intake 1
  • Weight loss program for overweight/obese patients 1

Common Pitfalls to Avoid

• Failing to rule out infection before injection 4
• Injecting without confirming the diagnosis when it's uncertain 4
• Neglecting to address the underlying hyperuricemia with appropriate ULT 6
• Starting ULT without providing prophylaxis against acute flares 1
• Focusing only on the acute management without implementing a long-term strategy for gout control 7