What is the assessment and plan for a patient with alcohol use disorder (AUD), acute gouty arthritis flare, and severe hypomagnesemia (low magnesium levels)?

From the Guidelines

The assessment and plan for this patient requires addressing three interconnected conditions: alcohol abuse, acute gout flare, and severe hypomagnesemia, with a focus on prioritizing morbidity, mortality, and quality of life as the primary outcomes. For alcohol abuse, I recommend initiating a medically supervised withdrawal protocol with benzodiazepines such as chlordiazepoxide (Librium) 50-100mg every 6 hours as needed, tapering over 3-5 days based on withdrawal symptoms, as supported by general medical knowledge and practices. Concurrently, start thiamine 100mg daily, folic acid 1mg daily, and multivitamins. Refer to addiction services for long-term management and consider naltrexone 50mg daily or acamprosate 666mg three times daily for maintenance therapy after detoxification, based on standard treatment protocols for alcohol use disorder.

For the gout flare, begin colchicine 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg daily for 7-10 days, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Alternatively, use naproxen 500mg twice daily or prednisone 40mg daily with a 5-day taper if NSAIDs are contraindicated, considering the patient's renal function and potential interactions with other medications, as suggested by the management of acute and recurrent gout guidelines from the American College of Physicians 1.

For severe hypomagnesemia, administer IV magnesium sulfate 2g over 1-2 hours, followed by 1g every 6 hours until serum levels normalize (typically >1.8 mg/dL), as a standard approach to correcting severe magnesium deficiency. Transition to oral magnesium oxide 400mg twice daily for maintenance. Monitor serum magnesium, calcium, and potassium levels daily during repletion, as alcohol abuse commonly causes multiple electrolyte abnormalities, and assess renal function before magnesium administration, as impaired kidneys may require dose adjustment, based on general principles of electrolyte management.

This comprehensive approach addresses the acute issues while establishing a foundation for long-term recovery from alcohol use disorder, which is essential to prevent recurrence of both gout flares and electrolyte disturbances, ultimately prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the Research

Assessment of Patient with Alcohol Abuse, Gout Flare, and Severe Hypomagnesemia

• The patient's condition is complex, involving alcohol abuse, a gout flare, and severe hypomagnesemia, which requires careful assessment and management 2.
• Alcohol abuse is a common cause of thiamine deficiency, which can lead to Wernicke's encephalopathy, a neurologic emergency that requires immediate attention 3, 4.
• Severe hypomagnesemia can also contribute to the development of Wernicke's encephalopathy, as magnesium is a cofactor in the phosphorylation of thiamine 5.
• The patient's gout flare may be related to the hypomagnesemia, as magnesium deficiency can contribute to the development of gout 2.

Plan for Management

• The patient should be treated with intravenous thiamine therapy to prevent or treat Wernicke's encephalopathy, with the optimum dosage remaining controversial 3.
• Magnesium replacement therapy should be initiated to correct the severe hypomagnesemia, with careful monitoring of serum magnesium levels 2, 6.
• The patient's gout flare should be managed with appropriate medication and lifestyle modifications.
• The patient's alcohol abuse should be addressed through counseling and support services to prevent further complications.
• Close monitoring of the patient's neurologic and renal function is essential to prevent long-term morbidity and mortality 5, 4.