Managing Gout in the ED: Toe Much Trouble

-Case-

A 56-year-old man with a history of HTN and CKD limps into the ED in visible discomfort. He says he woke up with intense pain in his right big toe. It’s red, swollen, and exquisitely tender. He admits to having a “big night” involving steak, seafood, and a few too many drinks. You take a look at his foot and see an angry, inflamed toe.

When you have a tender, swollen, erythematous joint, there are a few classic pathologies you should immediately think of. Remember how to differentiate between them, and know your options for treatment!

-Evaluation-

Gout is caused by monosodium urate crystal deposition in joints, most often due to hyperuricemia. Your patients in the ED will often complain of acute monoarthritis, typically in the first metatarsophalangeal (MTP) joint (aka podagra), but it can affect ankles, knees, or wrists.

• Classic Presentation:
  • Sudden onset, severe pain with erythema, warmth, swelling
  • Most often monoarticular
  • Common in middle-aged men, especially with comorbidities (CKD, obesity, HTN)

Common triggers include large meals consisting of red meat and seafood, along with heavy alcohol consumption. Additionally, thiazide diuretics and recent illness, dehydration, or trauma can flare a patient’s gout.

• Workup:
  • Largely clinical diagnosis 
  • Arthrocentesis indicated if uncertain or concern for septic arthritis; if performed, you will see negatively birefringent, needle-shaped urate crystals
  • Don’t forget – serum uric acid may be normal during acute flare!

-Management-

1. NSAIDs (first-line treatment): indomethacin, naproxen are best if there are no contraindications (ex., renal disease, PUD)
2. Colchicine: ideal to start within 36 hours of symptom onset; GI side effects are common
3. Steroids: oral prednisone is common for those who can’t take NSAIDs or colchicine
4. Make sure to avoid allopurinol or febuxostat during an acute flare! While these urate-lowering therapies are great for gout prophylaxis, they can actually worsen an acute attack

-Fast Facts-

• Don’t confuse gout for septic arthritis! If uncertain, tap the joint
  Treatment is about symptom relief, not lowering uric acid in the ED
• Avoid NSAIDs in CKD – use steroids instead
• Lifestyle counseling can prevent future flares (hydration, diet, limit alcohol)
  

Gout is a pathology all about sudden and severe pain. In the ED, quick symptom control is the name of the game. Whether it’s NSAIDs, colchicine, or steroids, know your options and when to rule out something worse!

Want to learn more? Listen to our great podcast episodes on gout and gout therapies or read our in-depth study guide on the topic!

Cheers,

Tamir Zitelny, MD