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Acute gout — ABIM Board MCQ

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ModerateRheumatology/Allergy/ImmunologyAcute goutABIM Board

A 58-year-old man with stage 3 chronic kidney disease and chronic heart failure develops abrupt, severe pain, erythema, and swelling of the first metatarsophalangeal joint. He is afebrile and has no systemic toxicity or overlying skin infection. Synovial fluid contains negatively birefringent, needle-shaped crystals; Gram stain and culture are negative. His medications include apixaban. Which of the following is the most appropriate treatment for this acute episode?

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Correct answer: E — A short course of oral prednisone

The correct answer is E. This is crystal-proven acute gout without evidence of septic arthritis. Glucocorticoids are a first-line treatment for gout flares and are the best listed choice because stage 3 CKD and heart failure increase the renal and cardiovascular risks of high-dose NSAIDs; apixaban also increases concern for NSAID-associated bleeding. Urate-lowering therapy may be started or adjusted during a flare when indicated, but it does not provide prompt anti-inflammatory relief and must not be used as sole acute therapy. Hyaluronic acid is used for osteoarthritis rather than crystal arthritis. Empiric vancomycin is inappropriate without clinical or synovial-fluid evidence of bacterial infection.

Reference: FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout, section on gout flare management. Arthritis Care & Research. 2020. https://pubmed.ncbi.nlm.nih.gov/32391934/