by Gout: Don’t Poo Poo Podagra
We spend a lot of time talking about septic joints/arthritis, when/when not to do the joint aspirations, but how about our forgotten mono-arthritic friend GOUT.
Picture yourself on an overnight shift, it’s 5:30a and on your board pops up a 50yr Male with Foot Pain. You walk over to the bed and see this foot
“Greaaaatttt” you think to yourself, “does this person want a work note? Are they seeking opiates? Do I attempt to do an arthrocentesis? How is this an EM problem?!?!”
WHO?: 1-4% of overall population. Think: Old Obese Male >50yrs, comorbidities of HTN, DM, HLD who eats a fat steak with beer and takes his diuretics regularly
HOW?: Hyperuricemia creating monosodium urate crystal growth by decreasing urate solubility. Macrophages then eat (phagocytize
) these crystals and activates the inflammatory cascade.
-Flares typically involve the first metatarsophalangeal (MTP) joint and to a lesser extent talar, subtalar, ankle and knee joints
-Pain is sudden, waking them from sleep with peak pain at 24 hours
–PE: red, swollen, tender, warm joint, and those with chronic gout may have multiple joint involvement
THE ED EVAL: Remember it is our job to rule out things that will kill or dismember our patients
**Acute Monoarticular arthritis must be considered septic arthritis until proven otherwise** –>Acute Gout attacks and septic arthritis can co-exist in a patient’s presentation
- Imaging:
- X-Ray: unless you are ruling out fx from concurrent trauma <<another risk factor for a gout flare>>, joint radiographs are essentially useless according to British Rheumotology Journal and mainly ordered for our ortho colleagues on consult
- US: useful for us to determine the largest effusion pocket (and have a successful tap!)
- Lab: CBC, ESR, CRP, uric acid
- keep in mind neither of these exams definitively confirm the diagnosis
- i.e. uric acid level does not have a useful PPV or NPV to rule in/rule out the diagnosis and is used for our outpatient counterparts to trend
- Arthrocentesis: GOLD STANDARD in diagnosis, yet, one retrospective chart review showed that on 8% of patients had arthrocentesis conducted….8%!!!
- WE SHOULD BE DOING MORE TAPS and of course, there is a decision rule for that:
- How do I tap the big toe?!: Distract the affected toe by applying gentle passive flexion while extending the toe and insert needle perpendicularly…or follow this YouTube vid: https://youtu.be/CzxCa3Rsom4
- Be sure to send: Cell count w/differential, gram stain and culture, and microscopic crystal analysis
- BOARDS BUZZ: needle-shaped; negatively birefringent crystals; negative gram stain; never give allopurinol for acute attacks
- WE SHOULD BE DOING MORE TAPS and of course, there is a decision rule for that:
Treatment: Rest & ICE to assist in reduction of inflammation
- NSAIDS: first line, counteracts prostaglandins.
- High dose for 7-10 days: Naproxen 500mg BID OR Ibuprofen 800mg PO TID
- Indomethacin linked to increased risk of toxicity so other NSAIDS preferred
- prescribe with a PPI and avoid in those with kidney failure or increased bleeding risk
- Colchicine: effect for patients within 12hrs onset, inhibits inflammatory cell migration.
- 1.2mg PO followed by 0.6mg one hour later (maximum of 3 doses or up to a total of 6mg)
- AVOID in those with renal or hepatic failure and ADJUST for those on macrolides and statins
- Prednisone: 30-50mg with a 10 day taper
- Opioids? One study showed 1 in 4 patients discharged with a prescription although is shows no roll in reducing inflammation or duration of the attack. Stop prescribing them!
Prevention: Be sure to spend time (or at least an EPIC print out) on ways to prevent gout attacks:
- Reduction in red meat, seafood, alcohol and fructose sweeteners, reduction in obesity and improve hydration
- Increase skimmed milk, yogurt, coffee, cherries and vitamin C intake to help reduce serum uric acid levels
- DO have them continue their uric-acid lowering agents if already on a regimen
- Follow up with their PCP or Rheum
