What are the signs and symptoms of a gout flare-up on the great toe and how is it typically treated?

Signs and Symptoms of Gout Flare-Up on the Great Toe

A gout flare-up affecting the great toe (podagra) presents with rapid onset of severe pain reaching maximum intensity within 6-24 hours, accompanied by marked swelling, erythema (redness) over the joint, and exquisite tenderness that makes even light touch unbearable. 1, 2

Classic Clinical Presentation

Timing and Pain Characteristics

• Pain develops extremely rapidly, typically reaching peak intensity within 12-24 hours of onset 1, 3
• The first metatarsophalangeal (MTP) joint is the initial site of involvement in approximately 50% of all gout cases 1, 4
• Patients often describe the pain as the worst they have ever experienced, with inability to tolerate even bedsheet contact 2, 5

Physical Examination Findings

• Marked erythema (redness) overlying the affected joint is highly characteristic and strongly suggestive of gout when combined with rapid onset 1, 3
• Severe swelling of the joint with loss of normal contours 1, 2
• Exquisite tenderness to palpation with restricted range of motion due to pain 3, 5
• The joint may appear warm to touch due to intense inflammation 2, 6

Pattern Recognition

• Monoarticular involvement (single joint) is typical, especially in early disease 1, 5
• Recurrent episodes separated by asymptomatic intervals (intercritical gout) are characteristic of the disease pattern 1, 6
• Male gender is a strong clinical predictor, as gout is much more common in men than premenopausal women 1, 6

Diagnostic Approach

Gold Standard Confirmation

• Joint aspiration with synovial fluid analysis demonstrating needle-shaped, negatively birefringent monosodium urate (MSU) crystals under polarized light microscopy provides definitive diagnosis with sensitivity and specificity approaching 100% 1, 3
• Even when crystals are identified, Gram stain and culture must still be performed as gout and septic arthritis can coexist 1, 3

Clinical Diagnosis When Aspiration Not Feasible

When joint aspiration cannot be performed, clinical diagnosis can be made with >80% accuracy based on the following features combined: 3

• Maximum inflammation developing within 1 day
• Redness observed over the affected joint
• First MTP joint specifically involved
• Previous similar attacks
• Hyperuricemia present

Important caveat: Hyperuricemia alone does not diagnose gout, and normal serum uric acid during an acute flare does not exclude gout 1, 3

Imaging When Diagnosis Uncertain

• Ultrasound should be the initial advanced imaging modality, looking for the "double contour sign" (74% sensitivity, 88% specificity) 1, 3
• Dual-energy CT (DECT) has 85-100% sensitivity and 83-92% specificity for detecting MSU crystal deposition, but is more expensive and involves radiation 3, 7

Immediate Treatment

First-Line Anti-Inflammatory Therapy

Treatment should be initiated as early as possible—ideally within 12 hours of symptom onset—for maximum effectiveness. 1

The following are equally recommended first-line options (choice based on contraindications and patient factors): 1

• Colchicine: Loading dose of 1 mg followed 1 hour later by 0.5 mg (total 1.5 mg on day 1), effective only when started within 12 hours of flare onset 1, 8

• NSAIDs (with proton pump inhibitor if appropriate): Full anti-inflammatory doses for 3-5 days 1

• Oral corticosteroids: Prednisolone 30-35 mg daily for 3-5 days 1

• Intra-articular corticosteroid injection: After joint aspiration if feasible 1

Critical Contraindications to Avoid

• Colchicine and NSAIDs must be avoided in patients with severe renal impairment (GFR <30 mL/min) 1
• Colchicine must not be given to patients receiving strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole, ritonavir) due to risk of fatal toxicity 1, 8

"Pill in Pocket" Strategy

• Fully informed patients should be educated to self-medicate at the first warning symptoms to maximize treatment effectiveness 1
• This approach is strongly recommended by EULAR guidelines given that early treatment (within 12 hours) dramatically improves outcomes 1

Long-Term Management Considerations

When to Consider Urate-Lowering Therapy

Urate-lowering therapy (ULT) is indicated for patients with: 2, 5

• Two or more gout flares per year
• Tophi (urate crystal deposits)
• Radiographic evidence of gouty arthropathy
• Chronic kidney disease

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis (low-dose colchicine 0.6 mg daily, NSAIDs, or low-dose corticosteroids) should be continued for at least 6 months after starting ULT to prevent flares triggered by mobilization of urate deposits 1, 5

Target Serum Uric Acid Levels

• Goal is <6 mg/dL for most patients 2, 5
• Goal is <5 mg/dL for patients with tophi to promote crystal dissolution 2

Common Pitfalls to Avoid

• Do not delay treatment waiting for laboratory confirmation—clinical diagnosis is sufficient to initiate therapy in typical presentations 1, 3
• Do not stop urate-lowering therapy during an acute flare, as this can prolong the attack 3
• Do not use high-dose colchicine (>1.8 mg in first 24 hours), as it provides no additional benefit and significantly increases adverse effects 1, 8
• Do not assume septic arthritis is excluded based on clinical appearance alone—if infection cannot be ruled out, joint aspiration with culture is mandatory 1, 3