What is the best course of treatment for a patient with a history of gout (gouty arthritis) presenting with significant pain at the ball of the feet, despite a negative computed tomography (CT) foot scan?

Management of Foot Pain in a Patient with History of Gout and Negative CT

Despite the negative CT scan, this patient likely has an acute gout flare affecting the metatarsophalangeal joints, and treatment should be initiated immediately with NSAIDs, colchicine, or corticosteroids within 24 hours of symptom onset for optimal pain relief. 1, 2

Diagnostic Considerations

Why CT Negativity Doesn't Rule Out Gout

• Standard CT lacks sensitivity for early gout: Conventional CT is not the preferred imaging modality for gout diagnosis—it typically shows erosions only in advanced disease 1
• Ultrasound or dual-energy CT (DECT) are superior: These modalities can detect monosodium urate crystal deposition (double contour sign, tophi, aggregates) that conventional CT misses 1
• Clinical diagnosis remains valid: The ball of the foot (metatarsophalangeal joints, especially the first MTP) is the classic location for acute gout, and diagnosis can be made using validated clinical criteria even without imaging confirmation 1, 3

Confirm the Diagnosis if Possible

• Joint aspiration with synovial fluid analysis is the gold standard: Demonstration of monosodium urate crystals allows definitive diagnosis 1, 3, 4
• Consider ultrasound as next imaging step: If aspiration is not feasible, ultrasound can identify features suggestive of MSU crystal deposition (double contour sign, tophi) with high sensitivity 1
• Rule out septic arthritis: If there is any suspicion of infection (fever, severe systemic symptoms, immunocompromised state), arthrocentesis is mandatory before starting corticosteroids 1

Immediate Treatment of Acute Gout Attack

First-Line Pharmacologic Options (Choose Based on Contraindications)

For mild-to-moderate pain (≤6/10) involving 1-3 small joints or 1-2 large joints, initiate monotherapy: 1, 2

• NSAIDs at full anti-inflammatory doses: Naproxen, indomethacin, or any NSAID at FDA/EMA-approved doses for acute pain; continue at full dose until attack completely resolves 1, 2

  • Contraindications: Avoid in heart failure, peptic ulcer disease, significant renal disease, or concurrent anticoagulation 2, 3

• Oral corticosteroids: Prednisone 0.5 mg/kg/day (or equivalent prednisolone 30-35 mg/day) for 5-10 days at full dose then stop, OR for 2-5 days then taper over 7-10 days 1, 2

  • Preferred in renal impairment: Corticosteroids are safer than NSAIDs or colchicine in patients with chronic kidney disease 2

• Low-dose colchicine: 1.2 mg at onset, followed by 0.6 mg one hour later (total 1.8 mg); effective only if started within 36 hours of symptom onset 1, 2, 5

  • Critical drug interactions: Reduce dose or avoid with strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, protease inhibitors) 2, 5
  • Renal dosing: In severe renal impairment (CrCl <30 mL/min), use single dose of 0.6 mg and do not repeat more than once every 2 weeks 5

For severe pain (≥7/10) or polyarticular involvement, use combination therapy: 1, 2

• Colchicine plus NSAIDs, OR
• Oral corticosteroids plus colchicine, OR
• Intra-articular corticosteroids (if 1-2 accessible joints) with any other modality 1, 2

Non-Pharmacologic Adjuncts

• Topical ice application: Appropriate as adjunctive measure to pharmacologic therapy 2
• Rest the affected joint: Useful during acute inflammation 6

Critical Timing

• Initiate treatment within 24 hours of symptom onset: Early treatment leads to better outcomes; delaying beyond 24 hours reduces effectiveness 1, 2
• Do NOT stop existing urate-lowering therapy: If patient is already on allopurinol or febuxostat, continue it without interruption during the acute attack 1, 2

Long-Term Management Considerations

When to Initiate Urate-Lowering Therapy (ULT)

ULT is indicated if this patient has: 1, 2

• Recurrent acute attacks (≥2 flares per year) 2, 3, 4
• Tophi (detected clinically or on ultrasound/DECT) 1, 2
• Radiographic changes of gout 1
• Chronic gouty arthropathy 1
• History of urolithiasis 4, 7

Do NOT initiate ULT during an acute attack—wait until the flare resolves 2, 3

ULT Regimen (When Indicated)

• Allopurinol is first-line: Start at ≤100 mg/day and titrate every 2-5 weeks to achieve target serum urate <6 mg/dL 2, 3, 7
• Mandatory anti-inflammatory prophylaxis: When starting ULT, use low-dose colchicine (0.6 mg once or twice daily), low-dose NSAIDs with gastroprotection, or low-dose prednisone for at least 6 months (or 3 months after achieving target urate if no tophi present) 2, 3, 7

Lifestyle Modifications

• Dietary changes: Reduce purine-rich foods (organ meats, shellfish), avoid alcohol (especially beer) and high-fructose corn syrup beverages; encourage vegetables and low-fat dairy products 2, 3, 4
• Weight loss for obese patients 2, 3
• Review medications: Consider switching from thiazide/loop diuretics to losartan (which increases uric acid excretion) or calcium channel blockers for hypertension management 8, 3

Common Pitfalls to Avoid

• Do not rely on negative conventional CT to exclude gout: Standard CT has poor sensitivity for early gout; use ultrasound or DECT if imaging confirmation is needed 1
• Do not use high-dose colchicine regimens: They cause significant GI toxicity with no additional benefit compared to low-dose regimens 1, 2
• Do not start ULT during an acute flare: This can paradoxically worsen or prolong the attack 2, 3
• Do not forget prophylaxis when initiating ULT: Inadequate prophylaxis duration leads to breakthrough flares and poor medication adherence 2, 3, 7
• Do not combine colchicine with strong CYP3A4 inhibitors in renal/hepatic impairment: This can cause life-threatening colchicine toxicity 5