What is the treatment plan for a patient with hyperuricemia, erythema of the great toe, and possible osteomyelitis?

From the Guidelines

The treatment plan for a patient with elevated uric acid (12.9), red great toe, and possible osteomyelitis should include both acute gout management and infection treatment, with a focus on initiating urate-lowering therapy (ULT) as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Acute Gout Management

• Initially, start with colchicine 0.6 mg twice daily for acute gout along with an NSAID like indomethacin 50 mg three times daily for 3-5 days if not contraindicated.
• For patients experiencing their first flare and with a uric acid level >9 mg/dl, ULT should be conditionally recommended, as per the guideline 1.

Long-term Uric Acid Management

• For long-term uric acid management, allopurinol should be initiated at 100 mg daily and gradually increased to achieve a uric acid level below 6 mg/dL, as recommended by the guideline 1.
• The guideline strongly recommends initiating ULT over no ULT for patients with radiographic damage attributable to gout, frequent gout flares (≥2/year), or subcutaneous tophi 1.

Infection Treatment

• For the possible osteomyelitis, empiric antibiotic therapy with vancomycin 15-20 mg/kg IV every 12 hours plus ceftriaxone 2g IV daily should be started after obtaining blood cultures and bone/joint fluid samples.
• MRI is essential to confirm osteomyelitis, and surgical debridement may be necessary depending on imaging findings.

Hospitalization and Supportive Care

• The patient should be hospitalized for initial management, with elevation of the affected foot, adequate hydration, and pain control.
• This comprehensive approach addresses both the inflammatory gout component and the potential bone infection, which requires aggressive treatment to prevent permanent joint damage and bone destruction. Note that the European Society of Cardiology guideline for the diagnosis and treatment of acute and chronic heart failure 2012 recommends considering allopurinol prophylaxis and using colchicine for pain relief in patients with hyperuricaemia/gout, but this is not directly applicable to the current scenario 1.

From the FDA Drug Label

Allopurinol tablets are indicated in: 1. the management of patients with signs and symptoms of primary or secondary gout (acute attacks, tophi, joint destruction, uric acid lithiasis, and/or nephropathy). The patient's symptoms, including elevated uric acid (12.9) and a red great toe, are consistent with gout.

• Treatment plan: Allopurinol can be used to manage the patient's gout.
• Dosage: The dose of allopurinol should be individualized for each patient, and the serum uric acid level should be used as an index to determine the correct size and frequency of dosage.
• Considerations: The patient's possible osteomyelitis should be addressed separately, as allopurinol is not indicated for the treatment of osteomyelitis. 2

From the Research

Treatment Plan for Elevated Uric Acid, Red Great Toe, and Possible Osteomyelitis

• The patient's symptoms, including elevated uric acid (12.9) and a red great toe, may be indicative of gout, a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within the synovium of joints 3, 4.
• The treatment plan for gout typically involves standard pharmacotherapies for acute flares, such as colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 3.
• Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares and are typically initiated after the acute flare has resolved 3, 4.
• In cases where the diagnosis of gout is uncertain, arthrocentesis should be performed to analyze synovial fluid or tophus, and to rule out septic joint 4.
• The presence of possible osteomyelitis may require additional treatment, such as antibiotics, and further evaluation to determine the extent of the infection.
• It is essential to note that the diagnosis of gout should not be excluded in the presence of normal serum uric acid levels if the clinical manifestations or the positive response to colchicine are suggestive of gout 5.
• The patient's treatment plan should be individualized, taking into account comorbidities, such as chronic kidney disease, and patient preference 3.

Medication Options

• Colchicine: may be effective in treating acute gout, with low-dose colchicine potentially improving treatment outcome compared to placebo with little or no increased risk of adverse events 6.
• NSAIDs: may be used to relieve pain in adults with acute gout episodes, but may have similar benefits and adverse events compared to low-dose colchicine 6.
• Corticosteroids: may be used to relieve pain and inflammation in acute gout episodes.
• Allopurinol and febuxostat: may be used to prevent gout flares, with allopurinol being a commonly used urate-lowering therapy 3, 4.