Can a patient with persistent right great toe pain and redness, previously treated for gout (gouty arthritis) 2 weeks ago with no resolution, be treated with colchicine and doxycycline (doxy)?

From the Guidelines

For persistent great toe pain and redness that hasn't resolved after gout treatment, the most appropriate next step is to reassess the diagnosis and consider alternative causes, rather than immediately adding colchicine and doxycycline. The patient's symptoms have not resolved after 2 weeks of gout treatment, which suggests that the initial diagnosis may be incorrect or that there is a concurrent condition, such as an infection, that needs to be addressed 1. According to the American College of Physicians guideline, colchicine is recommended for the treatment of acute gout, but it should be used at a low dose to minimize side effects 1.

Before starting any new medications, it's essential to consider the following:

• Reevaluate the diagnosis of gout and consider alternative causes of the patient's symptoms, such as cellulitis or septic joint.
• Perform a physical examination and obtain laboratory tests, including uric acid levels, white blood cell count, and possibly joint fluid analysis, to help clarify the diagnosis.
• Consider imaging studies to rule out other conditions that may be causing the patient's symptoms.

If the diagnosis of gout is confirmed, and the patient has not responded to initial treatment, low-dose colchicine (0.6mg once or twice daily) may be considered, but it should be used with caution and under medical supervision. Doxycycline (100mg twice daily) may be considered if there is a suspicion of infection, but it should be used judiciously and with careful monitoring for side effects, such as photosensitivity and gastrointestinal upset. The patient's symptoms and response to treatment should be closely monitored, and adjustments to the treatment plan should be made as needed.

From the FDA Drug Label

Colchicine Tablets, USP are a prescription medicine used to: prevent and treat gout flares in adults The patient has already been treated for gout 2 weeks ago and it has not resolved. Colchicine can be used to treat gout flares. However, there is no information about the use of doxy (likely doxycycline) in the treatment of gout. Key considerations:

• The use of colchicine for the treatment of gout flares is supported by the drug label.
• There is no information in the provided drug labels about the use of doxycycline for the treatment of gout.
• The patient should be evaluated for signs and symptoms of toxicities related to increased colchicine exposure as a result of a drug interaction.
• It is recommended to weigh the potential benefits and risks and carefully monitor patients for any signs or symptoms of muscle pain, tenderness, or weakness, particularly during initial therapy. 2 2 2

From the Research

Great Toe Pain and Redness

• The patient has been experiencing great toe pain and redness for 1 month and was treated for gout 2 weeks ago, but the symptoms have not resolved.
• The question is whether the patient can be treated with colchicine and doxycycline (doxy).

Treatment Options for Acute Gout

• According to a Cochrane Review 3, low-dose colchicine may be an effective treatment for acute gout when compared to placebo, with low-quality evidence suggesting that it may improve treatment outcome with little or no increased risk of adverse events.
• The same review found that high-dose colchicine may also improve symptoms, but with an increased risk of harms.
• Another Cochrane Review 4 found that non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain at 24 hours, but may have little to no effect on function, inflammation, or adverse events for treatment of acute gout.

Combination Therapy

• There is limited evidence on the use of combination therapy with colchicine and doxycycline for acute gout.
• A review of treatments for acute gout 5 found that colchicine, NSAIDs, and glucocorticoids are all effective treatments, but there was insufficient evidence to rank them.
• The review also found that low-dose colchicine was safer than high-dose colchicine, and that systemic glucocorticoids appeared safer than NSAIDs.

Conclusion Not Applicable

References Not Applicable

Treatment Decision

• Based on the available evidence, colchicine may be a viable treatment option for the patient's acute gout, but the decision to use combination therapy with doxycycline should be made on a case-by-case basis, taking into account the patient's individual circumstances and medical history.
• It is essential to carefully evaluate the patient's symptoms and medical history before making a treatment decision, and to consider the potential benefits and harms of different treatment options 3, 4, 5.