What is the recommended treatment for a patient with suspected gouty arthritis and inflammatory arthropathy, presenting with ankle spurring, soft tissue swelling, and erosions at the anterior distal tibia and medial malleolus?

Treatment of Suspected Gouty Arthritis with Erosive Changes

For this patient with imaging findings consistent with gouty arthritis showing erosions and tophi, immediate treatment of any acute inflammation combined with prompt initiation of urate-lowering therapy (ULT) is essential, as the presence of erosions and tophi mandates long-term ULT regardless of attack frequency. 1, 2

Immediate Management of Acute Inflammation

If the patient is currently experiencing an acute attack (joint pain, swelling, warmth):

• Start anti-inflammatory therapy within 24 hours of symptom onset for optimal outcomes 2
• First-line options (all Level A evidence):
  • NSAIDs: Indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper 3, 1
  • Colchicine: 1.2 mg loading dose, followed by 0.6 mg one hour later 2, 1
  • Corticosteroids: Prednisone 30-35 mg daily for 3-5 days 2, 1
• Avoid NSAIDs if the patient has renal impairment, cardiovascular disease, or gastrointestinal risk factors; use colchicine or corticosteroids instead 4

Mandatory Urate-Lowering Therapy (ULT)

The presence of erosions on imaging constitutes an absolute indication for ULT, independent of attack frequency 1:

Initiation Strategy

• Start allopurinol 100 mg daily, even during an acute attack 2, 4
• Do NOT stop ULT if started during an acute flare—continuing therapy is critical 2, 4
• Escalate dose by 100 mg every 2-4 weeks until serum uric acid reaches target 4
• Target serum uric acid <6 mg/dL (or <5 mg/dL given the presence of erosions suggesting severe disease) 4, 1

Alternative ULT Agent

• Febuxostat is the alternative if allopurinol is not tolerated or contraindicated 2, 1

Mandatory Anti-Inflammatory Prophylaxis During ULT Initiation

Critical pitfall to avoid: Failing to provide prophylaxis when starting ULT leads to increased acute attacks 2, 4:

• Colchicine 0.5-1 mg daily for at least 6 months when initiating or escalating ULT 2, 4
• Adjust colchicine to 0.5 mg daily or every other day if creatinine clearance is 30-50 mL/min 4
• Low-dose NSAIDs are an alternative if colchicine is contraindicated 4
• Low-dose corticosteroids can be used when both colchicine and NSAIDs are contraindicated 4

Address Contributing Factors

Review and modify medications that worsen hyperuricemia 1, 4:

• If taking thiazide or loop diuretics, switch to losartan (which has uricosuric effects) or calcium channel blockers 4, 1
• Consider fenofibrate if hyperlipidemia is present, as it has uricosuric properties 4
• Do NOT stop low-dose aspirin if taken for cardiovascular indications 4

Non-Pharmacologic Measures

Every patient requires comprehensive lifestyle modification 4, 1:

• Weight loss if obese 4
• Avoid alcohol, especially beer and spirits 4
• Eliminate sugar-sweetened beverages and high-fructose foods 4
• Reduce red meat and seafood intake 4
• Encourage low-fat dairy products 4

Long-Term Monitoring

• Continue ULT indefinitely to maintain serum uric acid <6 mg/dL 1, 2
• Monitor serum uric acid levels regularly to ensure target is maintained 1
• Continue prophylaxis until all tophi resolve and patient is attack-free for at least 6 months 2, 4

Common Pitfalls to Avoid

• Never discontinue ULT during an acute attack—this perpetuates the cycle of recurrent flares 2, 4
• Never start ULT without concurrent anti-inflammatory prophylaxis—this triggers mobilization flares 2, 4
• Never use high-dose colchicine regimens—low-dose provides similar efficacy with fewer side effects 2
• Never delay ULT in patients with erosions or tophi—these findings mandate immediate treatment 1