What is the next step for managing severe gout (gouty arthritis) in the left foot with significant pain, rated 8 out of 10, and normal uric acid levels (hyperuricemia not present)?

From the Guidelines

The next step for this patient with acute gout pain is to treat the current flare with anti-inflammatory medication rather than immediately starting Allopurinol. I recommend starting with an NSAID like naproxen 500mg twice daily or indomethacin 50mg three times daily for 3-5 days if there are no contraindications, as suggested by the American College of Physicians guideline 1. Alternatively, colchicine 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until the flare resolves could be used, with evidence showing that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events 1. For severe pain, a short course of prednisone 30-40mg daily for 3-5 days with a taper might be appropriate. Allopurinol should not be initiated during an acute attack as it can worsen symptoms; it should be started after the flare has resolved, typically 2-4 weeks later, as recommended by the American College of Physicians guideline 1. Despite the normal uric acid level (5.5), the clinical presentation strongly suggests gout, and uric acid levels often decrease during acute attacks. The patient should also be advised to:

• rest the affected foot
• apply ice for 20 minutes several times daily
• elevate the foot when possible
• maintain adequate hydration A follow-up appointment should be scheduled after the acute phase to discuss long-term urate-lowering therapy with Allopurinol if this is a recurrent issue, with evidence showing that urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks 1.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis The next step is to consider indomethacin for the treatment of acute gouty arthritis, as it has been found to be effective in relieving pain and reducing inflammation.

• The patient's uric acid level is within normal limits, which is not a contraindication for the use of indomethacin.
• The patient's pain level is a high 8 out of 10, which is consistent with the need for effective pain management.
• Indomethacin may be a suitable option for the patient, given its efficacy in treating acute gouty arthritis 2.

From the Research

Next Steps for Gout Management

The patient is experiencing a high level of pain due to gout in their left foot, with a pain level of 8 out of 10. The patient's uric acid level is 5.5, which is considered normal.

• The patient is requesting to discuss the possibility of taking Allopurinol for gout management 3.
• According to the studies, Allopurinol is an effective treatment for reducing concentrations of uric acid, but renal function guides the starting dose and the baseline serum uric acid concentration guides the maintenance dose 3.
• For acute gout management, non-steroidal anti-inflammatory drugs, colchicine, and corticosteroids are options, and they are equally efficacious, with comorbidities guiding the best choice 3, 4, 5.
• The patient's high pain level and normal uric acid level suggest that acute gout management may be the priority, and Allopurinol may not be the immediate solution 4, 6, 5.
• Other treatment options for acute gout include NSAIDs, COX-2 inhibitors, systemic corticosteroids, colchicine, and IL-1 inhibitors, which have been shown to be effective in reducing pain and inflammation 4, 5.
• The choice of treatment should be based on the patient's individual characteristics, including comorbidities and renal function 3, 6, 7.

Treatment Options

• NSAIDs, such as ibuprofen or naproxen, may be considered as a first-line treatment for acute gout 4, 5.
• Colchicine may also be an option, particularly for patients who cannot tolerate NSAIDs 4, 5.
• Corticosteroids, such as prednisone, may be used for acute gout management, especially for patients with contraindications to NSAIDs or colchicine 4, 5.
• IL-1 inhibitors, such as canakinumab, may be considered for patients who do not respond to other treatments 4, 5.

Urate Lowering Therapy

• Allopurinol may be considered for urate lowering therapy, but the patient's normal uric acid level and high pain level suggest that acute gout management may be the priority 3, 7.
• Febuxostat is another option for urate lowering therapy, but it has received a U.S. FDA black box warning for cardiovascular safety 7.
• Novel uricosurics, such as verinurad and arhalofenate, are being developed and may be considered in the future 7.