What is the appropriate treatment for a patient in their 50s with acute gouty arthritis, presenting with swelling of the right elbow and negatively birefringent, needle-shaped crystals in the joint fluid, after a night of consuming beer and eating venison?

Treatment of Acute Gouty Arthritis of the Elbow

For this patient with acute gout affecting a single large joint (elbow), initiate pharmacologic therapy immediately with one of three first-line options: NSAIDs at full anti-inflammatory doses, oral colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days). 1, 2, 3

Immediate Management (Within 24 Hours)

Treatment must be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3 The elbow qualifies as a large joint, placing this patient in the category of 1-2 large joint involvement, where monotherapy is appropriate. 1

First-Line Treatment Options

NSAIDs (Preferred for Most Patients):

• Use full anti-inflammatory doses: indomethacin 50 mg three times daily, naproxen 500 mg twice daily, or sulindac at approved doses 1, 4
• Continue at full dose until the attack completely resolves 1, 3
• Avoid in patients with heart failure, peptic ulcer disease, or significant renal disease 2, 3

Oral Colchicine (If Started ≤36 Hours from Onset):

• Loading dose: 1.2 mg followed by 0.6 mg one hour later 1, 3
• After 12 hours, continue 0.6 mg once or twice daily until attack resolves 1
• This low-dose regimen is equally effective as high-dose regimens with significantly fewer gastrointestinal side effects 3, 5
• Requires dose adjustment in moderate-to-severe chronic kidney disease and with certain drug interactions (CYP3A4 and P-glycoprotein inhibitors) 1

Oral Corticosteroids:

• Prednisone 0.5 mg/kg per day for 5-10 days 2, 3
• Particularly useful when NSAIDs and colchicine are contraindicated 3
• Intra-articular corticosteroid injection is highly effective for single joint involvement and could be considered for this elbow presentation 3

Critical Management Principles

If the patient is already on urate-lowering therapy (allopurinol, febuxostat), continue it without interruption during the acute attack. 1, 2, 3 Discontinuing urate-lowering therapy during acute attacks worsens and prolongs the attack. 3, 5

Monitor treatment response: Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours. 1, 3 If response is inadequate, consider combination therapy with two agents from different classes. 3

Addressing Precipitating Factors

This patient's gout attack was triggered by beer consumption and purine-rich venison. Counsel the patient to avoid alcoholic drinks (especially beer) and purine-rich foods such as organ meats and game meats. 2, 6 Beer is particularly problematic as it contains both alcohol and purines. 6

Long-Term Considerations After Acute Attack Resolution

After the first gout attack, assess for indications to initiate urate-lowering therapy, which include recurrent acute attacks, tophi, chronic gouty arthropathy, or radiographic changes of gout. 2, 3 If urate-lowering therapy is indicated and initiated, mandatory anti-inflammatory prophylaxis must be provided with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs for at least 6 months, or 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi. 2, 3, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
• Never discontinue established urate-lowering therapy during an acute attack 1, 2, 3
• Avoid using high-dose colchicine regimens (previously used dosing of 1 mg every 2 hours), which cause significant gastrointestinal toxicity without additional benefit 5
• Failing to provide prophylaxis when initiating urate-lowering therapy leads to increased flare frequency and poor medication adherence 2, 3, 5