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Difficulty: EasyRheumatology and Immunology

A 48-year-old man comes to the clinic reporting severe, throbbing pain in his right big toe that awoke him from sleep last night. He states the pain is so intense that even the weight of a bedsheet is intolerable. He has no recent history of trauma or previous similar episodes. His medical history is notable for essential hypertension, for which he takes hydrochlorothiazide. Vital signs are within normal limits. Physical examination reveals a markedly swollen, erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Which of the following is the most appropriate initial medication for this patient's acute condition?

  1. Oral indomethacinAnswer
  2. B
    Oral allopurinol
  3. C
    Intravenous ceftriaxone
  4. D
    Oral probenecid
  5. E
    Oral febuxostat

Answer

Oral indomethacin is the most appropriate initial medication for this acute gout flare.
The patient presents with podagra (acute inflammation of the first metatarsophalangeal joint), which is the classic manifestation of an acute gout flare. His use of a thiazide diuretic (hydrochlorothiazide) is a well-known risk factor because it decreases the renal excretion of uric acid. The most appropriate initial treatment for an acute gout flare is an anti-inflammatory medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, naproxen, or ibuprofen are considered first-line therapy for patients without specific contraindications (like severe renal impairment or active peptic ulcer disease).

Step-by-Step Solution

1
Identify the clinical syndrome based on the patient's presentation.
The patient has sudden onset of severe monoarticular arthritis affecting the first metatarsophalangeal joint (podagra).
Recognizing podagra is key to suspecting acute gout, especially in a patient with risk factors such as thiazide diuretic use.
2
Determine the phase of the disease.
The patient is experiencing an acute inflammatory flare, rather than requiring chronic intercritical management.
Treatment strategies differ completely between acute flares (anti-inflammatory) and chronic management (urate-lowering).
3
Select the appropriate pharmacotherapy for the acute phase.
NSAIDs, colchicine, or glucocorticoids are indicated. Indomethacin is a commonly used and highly effective NSAID for this purpose.
The immediate goal of acute management is to reduce severe inflammation. Urate-lowering therapies are reserved for long-term prevention.

Key Concept

The first-line management of an acute gout flare involves anti-inflammatory agents such as NSAIDs, colchicine, or glucocorticoids. Urate-lowering therapy should not be initiated during an acute flare.
Estimated Time:45s
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Topics

Rheumatology and Immunology

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