What is the best course of action for a patient with acute right big toe pain, mild redness, and swelling, suspected to be gout?

Management of Acute Gout in the Right Big Toe

For a patient with acute right big toe pain, mild redness, and swelling suspected to be gout, the most appropriate first-line treatment is low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) or an NSAID at full anti-inflammatory dose, started as soon as possible within 24 hours of symptom onset. 1

Diagnosis Considerations

• When synovial fluid aspiration is not possible, a clinical diagnosis of gout can be made based on the classic presentation of podagra (first metatarsophalangeal joint pain), rapid onset of severe pain, erythema, and swelling 2, 3
• Checking serum uric acid levels is helpful, though normal levels do not rule out acute gout as levels may be normal during an acute attack 1, 4

First-Line Treatment Options

Colchicine

• Most effective when started within 12-36 hours of symptom onset 1
• Recommended dosing: 1.2 mg initially, followed by 0.6 mg one hour later 1, 2
• Low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2
• Avoid in patients with severe renal impairment or those taking strong P-glycoprotein/CYP3A4 inhibitors 1, 2

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1
• FDA-approved NSAIDs for gout include naproxen, indomethacin, and sulindac 1
• Indomethacin is a potent prostaglandin synthesis inhibitor that effectively reduces pain and inflammation 5
• Contraindicated in patients with significant renal disease, heart failure, or cirrhosis 1, 6

Corticosteroids

• Excellent alternative when NSAIDs or colchicine are contraindicated 1, 6
• Oral prednisone (30-35 mg/day for 3-5 days) is effective 1, 6
• Intra-articular injection is highly effective for single joint involvement like the first MTP joint 1, 6

Treatment Algorithm

1. For mild to moderate pain with single joint involvement:

   • Start with either low-dose colchicine or an NSAID at full dose 1, 2
   • Continue treatment until symptoms completely resolve 1

2. For severe pain or inadequate response to initial therapy:

   • Consider combination therapy (colchicine plus NSAID) 1, 6
   • Or switch to oral corticosteroids if initial therapy is ineffective 1

3. For patients with contraindications to NSAIDs and colchicine:

   • Use oral corticosteroids or intra-articular injection 1, 6

Important Considerations

• Do not interrupt ongoing urate-lowering therapy during an acute attack 1, 6
• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement at 24 hours 1
• For recurrent attacks, consider initiating urate-lowering therapy with allopurinol after the acute attack resolves 7
• Prophylactic therapy should be considered when starting urate-lowering therapy to prevent flares 6, 7

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1
• Using high-dose colchicine regimens that cause significant gastrointestinal side effects 1, 2
• Failing to adjust colchicine dosing in patients with renal impairment 1, 2
• Not educating patients about the "pill in the pocket" approach for future attacks 1, 6
• Initiating urate-lowering therapy during an acute attack, which can worsen symptoms 1, 4

Non-Pharmacologic Measures

• Rest the affected joint 4, 3
• Apply ice to reduce inflammation 6, 4
• Elevate the affected limb 4, 3
• Avoid alcohol consumption, especially beer 6, 4
• Limit intake of purine-rich foods (organ meats, shellfish) 6, 4