Can intra‑articular glucocorticoid injection be given for acute gout of the first metatarsophalangeal joint?

Intra-articular Corticosteroid Injection for Acute Gout of the First MTP Joint

Yes, intra-articular glucocorticoid injection is explicitly recommended as a first-line treatment option for acute gout of the first metatarsophalangeal joint, particularly when involving 1-2 joints. 1

Guideline-Based Recommendations

The EULAR 2021 guidelines explicitly state that "recommended first-line options for acute flares are colchicine, oral corticosteroid, or articular aspiration and injection of corticosteroids." 1 This places intra-articular injection on equal footing with oral therapies as a primary treatment modality.

The American College of Rheumatology 2012 guidelines specifically recommend intra-articular injection of corticosteroids for involvement of 1-2 joints, with dose depending on the size of the joint (Evidence B). 1 For the first MTP joint specifically, this translates to a practical treatment approach that is both effective and safe.

FDA-Approved Indication

The FDA label for triamcinolone acetonide explicitly lists "acute gouty arthritis" as an approved indication for intra-articular administration, confirming regulatory support for this approach. 2

Practical Implementation

Dosing and Technique

• Inject 0.5 mL (20 mg) of triamcinolone acetonide mixed with 0.5 mL of 2% lidocaine into the affected first MTP joint. 3 This specific regimen has been studied and shown to be effective.
• Consider ultrasound guidance to improve accuracy, as imaging guidance may enhance precision, particularly in smaller joints like the first MTP. 1, 3 The EULAR guidelines note that accuracy depends on joint size and clinician expertise, and ultrasound can improve outcomes. 1
• Always use strict aseptic technique when performing the injection to minimize infection risk. 1

Expected Clinical Response

• Patients typically experience a 48 mm reduction in pain score (on a 100 mm visual analog scale) within 48 hours of injection. 3 This represents substantial and rapid pain relief.
• General disability and walking disability scores improve by approximately 35-39 mm within 48 hours. 3
• The treatment is effective and safe, with no adverse events reported in clinical studies of first MTP joint injections for acute gout. 3

When Intra-articular Injection is Particularly Advantageous

Intra-articular injection should be strongly considered as the preferred first-line option in the following clinical scenarios:

• Monoarticular or oligoarticular involvement (1-2 joints), where targeted therapy provides rapid relief without systemic effects. 1
• Patients who are NPO (nil per os) due to surgical or medical conditions, where oral medications cannot be administered. 1
• Patients with contraindications to systemic therapies, including severe renal impairment (where NSAIDs and colchicine carry unacceptable risks), active peptic ulcer disease, cardiovascular disease, or those on anticoagulation. 1, 4
• Patients requiring rapid, localized pain control without the systemic side effects of oral corticosteroids (hyperglycemia, mood changes, fluid retention). 4

Diagnostic Utility

Beyond therapeutic benefit, intra-articular injection can serve a diagnostic purpose. 1 Aspiration of joint fluid before injection allows for synovial fluid analysis with direct visualization of monosodium urate crystals, which remains the gold standard for gout diagnosis. 5, 6

Ultrasound Findings in Acute Gout of the First MTP

Ultrasound is more sensitive than conventional radiography for detecting characteristic features of gout in the first MTP joint, including erosions, joint effusion, synovial hypertrophy, tophus-like lesions, double contour sign, hyperechoic spots, and increased power Doppler signal. 3 These findings can confirm the diagnosis and guide injection technique.

Important Safety Considerations

• Avoid overuse of the injected joint for 24 hours following injection, but do not immobilize the joint, as immobilization is discouraged. 1
• Diabetic patients should be counseled about transient hyperglycemia risk (though this is minimal with intra-articular injection compared to systemic steroids) and advised to monitor glucose levels, particularly days 1-3 post-injection. 1
• Intra-articular injection is not contraindicated in patients with bleeding disorders or those taking antithrombotic medications, unless bleeding risk is exceptionally high. 1
• Ensure appropriate diagnosis has been made before administering intra-articular steroids, as the EULAR guidelines emphasize that steroids should not be given until contraindications are ruled out and diagnosis is confirmed. 1

Common Pitfalls to Avoid

• Do not avoid intra-articular injection simply because the joint is small—the first MTP joint is an appropriate target with proper technique, and ultrasound guidance can enhance accuracy. 3
• Do not assume oral therapy is always superior—for monoarticular first MTP involvement, intra-articular injection provides equivalent or superior outcomes with fewer systemic effects. 1, 3
• Do not delay treatment—pharmacologic therapy should be initiated within 24 hours of acute gout attack onset for optimal efficacy. 4

Evidence Quality

While a 2013 Cochrane review found no randomized controlled trials specifically evaluating intra-articular glucocorticoids for acute gout 7, the subsequent inclusion of this modality in both EULAR (2021) and ACR (2012) guidelines as a first-line option reflects expert consensus based on extrapolation from other inflammatory arthritides and observational data. 1 The 2015 prospective study by Kim et al. provides direct evidence of efficacy and safety for first MTP joint injections in acute gout. 3