Treatment Approaches to Case 1

Benjamin W. Friedman, MD, MS: How would you guys approach this case? This patient is on a nonspecific analgesic, naproxen. He also has some disease-specific treatment, colchicine and the allopurinol. He doesn’t have any allergies, and he’s relatively young and reasonably healthy, so there are a lot of treatment options. Does anybody want to take this first and say how they would go about assessing this gentleman?

Francesca Beaudoin, MD, MS, PhD: I can take a stab at it, Ben. Wearing my ED [emergency department] hat for a second, any time I hear worsening pain or failure to respond to therapy, I definitely want to do a check and say, “Is this truly what’s going on?” and make sure there isn’t something else, such as infection, osteomyelitis, foreign body—we could make a list. But let’s assume that we all agree that this is gout, podagra, first metatarsal, with severe pain.

The things that are immediately running through my head are the history of diabetes and hypertension, so I’m thinking about that as we’re choosing therapies. Steroids may be indicated, but with the diabetes, how well is the diabetes controlled? Are the steroids going to cause a problem? I’m not loving the nonsteroidal-colchicine combination in somebody with diabetes and hypertension. But that aside for the moment, what do we do at this point in somebody who has worsening pain? Have we maximized the nonpharmacologic options? Can we put this person on crutches and a postoperative shoe to stabilize that joint so it isn’t moving as much? Then what are our other therapeutic options?

Thinking about steroids, I probably wouldn’t inject that joint. It’s smaller than what most practitioners would typically inject with steroids. Regional anesthesia could be a potential option, but not widely used for acute gouty arthritis, at least in the ED setting. Then there are opioids. There are more expensive options for acute gout, such as interleukin-1 inhibitors, but I don’t know how widely available those are. That certainly wouldn’t be my first go-to. Those are the things that I’m working down as I’m thinking about this, because we need to do better with this person who has worsening pain that’s presumably impairing function. We should do all those assessments and get to the bottom of things. Jeff, Paul, what do you think?

Jeff Gudin, MD: Ben, I agree with Francesca. Here you have an obese, diabetic, drinking truck driver who has probably been relatively noncompliant with therapy and wants to take pills to get rid of his pain. Obviously, steroids are a concern with his diabetes, but sometimes you have do it. This patient needs rest, elevation, and probably warmth over ice. Francesca said to give him some crutches or an ambulatory assist device. I’d look into topical analgesics, even though it’s hard to get them into a red, swollen joint, topical local anesthetics, and topical menthol/methyl salicylate–based products. I’m clearly not a gout expert, but I’d try to talk him off the ledge as he’s in this acute process, telling him that this is more than likely going to resolve in the next couple of weeks.

Paul Arnstein, RN, PhD, FAAN: I agree that we need to take a 2-pronged approach in terms of making sure the diagnosis is right and getting the right disease-modifying treatment and pain control medications on board, as well as looking at some of the nonpharmacologic issues. As we talked about earlier, he has some of the psychosocial factors that drive pain levels up. He’s out of a job, recently divorced, smoking, and has very limited social resources. Paying attention to some of those factors in addition to getting the medication regimen right for this patient and considering the comorbidities are all factors that we’d have to take into account.

Transcript Edited for Clarity