ABSTRACT
A 60-year-old man has an acutely painful third toe and the chronic hand findings shown here. All of the following treatments would be appropriate in this setting except:
a. Allopurinol b. Colchicine c. Indomethacin d. Intra-articular corticosteroid injection e. Ibuprofen
• Gout characteristically causes extreme pain with inflammation of a single joint in the lower extremity, but other joints can be involved
• Diagnosis: joint fluid aspiration shows negatively birefringent needle-shaped uric acid crystals under polarized light
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for initial treatment. Colchicine is another option
• Intra-articular corticosteroids, intramuscular adrenocorticotropic hormone, and systemic corticosteroids can be used for patients unable to take NSAIDs
• Shifts in uric acid concentrations are more important than absolute levels for flare development
• Colchicine has been used for many years to prevent gout attacks and is effective in about 85% of patients, but it is not as popular now because of the side effect profile and the availability of other preventive options
• Allopurinol inhibits xanthine oxidase and is generally the prophylactic medication of choice
• Although allopurinol is effective for tophaceous gout in the intercritical period, it should not be used during an acute flare because the disease may worsen
• Uricosuric agents (probenecid, sulfinpyrazone, benzbromarone) occasionally are used for prophylaxis but less so than allopurinol because of multiple daily dosings, inhibition by salicylates, decreasing effectiveness with worsening renal function, and inappropriateness for use in patients who have had nephrolithiasis
• Allopurinol has none of the disadvantages listed above
