A 48-year-old man with a history of hypertension, peptic ulcer disease (gastric ulcer 1 year ago), and morbid obesity presents to the emergency department complaining of excruciating pain in his left big toe and both ankles. This is similar to a painful episode he had with his left toe and ankle 6 months ago. On examination, his left great toe and both ankles are red, swollen, and warm to the touch. He describes the pain as throbbing and rates it as a 10/10 (where 10 is the worst pain he has ever experienced). He admits to drinking a six pack of beer on weekends. He weighs 150 kg (330 lb) and is 5 ft, 9 in. (175 cm) tall. Medications include chlorthalidone 25 mg/day and panto-prazole 40 mg/day. Serum creatinine is 1.0 mg/dL (88 ^mol/L).
What information suggests gout as the cause of his symptoms?
What risk factors for gout does he have?
If the diagnosis is an acute attack of gouty arthritis, what treatment plan would you recommend for this patient?
Too rapid tapering of corticosteroids can cause a rebound gouty flare. To prevent this flare, low-dose colchicine (0.6 mg orally daily) sometimes is added to systemic corticosteroid regimens. This is probably unnecessary if an adequate taper is prescribed.
Short-term adverse effects from corticosteroids include fluid retention, hyperglycemia, CNS stimulation, weight gain, and increased risk of infection. Patients with diabetes should have blood glucose levels monitored carefully during the corticoster-oid course.
Corticotrophin (adrenocorticotropic hormone [ACTH]) has been used for acute gouty flares. Worldwide supply problems and the possible superiority of traditional corticosteroids have resulted in decreased use.21
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