What treatment options are available for acute gouty arthritis in the left foot with severe pain, elevated uric acid levels, and no prior use of Allopurinol (generic name: Allopurinol)?

From the Guidelines

I strongly recommend that you be seen urgently for your acute gout attack, and we should discuss treatment options such as colchicine, NSAIDs, or corticosteroids to manage your severe pain, rather than starting Allopurinol immediately. While Allopurinol is used for long-term gout management, it's not appropriate during an acute flare as it can actually worsen symptoms initially, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. For your current severe pain, treatment typically includes anti-inflammatory medications like colchicine, NSAIDs (such as naproxen or indomethacin), or corticosteroids. These medications reduce inflammation and provide pain relief.

• Your uric acid level of 5.5 is actually within normal range, but this doesn't rule out gout as levels often fluctuate, especially during attacks.
• Once your acute attack resolves, we can discuss starting Allopurinol (typically at 100mg daily, gradually increasing if needed) for long-term prevention if appropriate.
• In the meantime, elevate your foot, apply ice for 20 minutes several times daily, drink plenty of water, and avoid alcohol and purine-rich foods like red meat and seafood.
• These measures help because gout occurs when uric acid crystals accumulate in joints, causing intense inflammation and pain, as explained in the 2016 updated EULAR recommendations 1.
• It's also important to note that lifestyle changes, such as weight loss, regular exercise, and a diet low in purines and sugar-sweetened drinks, can help reduce the frequency of gout attacks, as suggested by the evidence 1.

From the FDA Drug Label

An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained. The patient's uric acid level is 5.5, and they have never taken Allopurinol before.

• Key consideration: The patient is experiencing a high level of pain due to gout, with a pain level of 8 out of 10.
• Clinical decision: It is recommended to start with a low dose of Allopurinol (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained.
• Important note: The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases, and it may require several months to deplete the uric acid pool sufficiently to achieve control of the acute attacks 2.

From the Research

Gout Management and Treatment

The patient is experiencing a high level of pain (8 out of 10) due to gout in their left foot, which has been ongoing since Friday. The patient's uric acid level is 5.5, and they have never taken Allopurinol before.

• The patient's symptoms are consistent with acute gout, which is typically characterized by swelling, pain, or tenderness in a peripheral joint or bursa 3.
• Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, and are equally efficacious, with comorbidities guiding the best choice 4, 5.
• Allopurinol is an effective treatment for reducing concentrations of uric acid, and the starting dose is guided by renal function, while the maintenance dose is guided by the baseline serum uric acid concentration 4.
• The patient's uric acid level of 5.5 is relatively low, but still may benefit from urate-lowering therapy, especially if they experience frequent flare-ups or have other indications for long-term therapy, such as chronic kidney disease or tophus formation 3, 6.

Treatment Options

• Allopurinol is a commonly used urate-lowering therapy, and is considered a first-line agent for patients with gout 4, 7.
• Febuxostat is another xanthine oxidase inhibitor that is clinically equivalent to Allopurinol, but has received a U.S. FDA black box warning for cardiovascular safety 4, 7.
• Other treatment options, such as uricosuric drugs (e.g. probenecid) and novel therapies (e.g. lesinurad, pegloticase), may be considered for patients who do not respond to first-line agents or have contraindications to their use 4, 6, 7.

Next Steps

• The patient should be evaluated for underlying comorbidities and risk factors for gout, such as hypertension, obesity, and diet 3.
• Laboratory tests, including renal function and serum uric acid level, should be monitored regularly to guide treatment decisions 4, 6.
• The patient should be educated on lifestyle modifications, such as diet and exercise, to help prevent future gout flare-ups 7.