A 57-year-old man comes to the emergency department because of excruciating pain in his
right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no
chronic medical conditions, does not take any medications, and denies any similar episodes in
the past. He admits to a few “drinking binges” over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show:
Serum
Leukocytes…16,000/mm3
Uric acid…15 mg/dL
Calcium…9 mg/dL
Which of the following is the most appropriate pharmacotherapy?
A. Allopurinol
B. Ceftriaxone
C. Indomethacin
D. Probenecid
E. Sulfinpyrazone
Explanation:
The correct answer is C. This patient has the classic presentation of a patient with acute gouty
arthritis with the sudden onset of severe pain (typically in the middle of the night), swelling,
erythema and warmth of a single joint. Low-grade fever and leukocytosis may be seen. It is more
common in men and it is associated with hyperuricemia, usually due to decreased renal excretion
of uric acid. Common causes are thiazides and alcohol. Diagnosis is made by examination of
joint fluid under polarizing light. Negatively birefringent, needle-shaped crystals within
polymorphonuclear leukocytes, hyperuricemia, and acute monoarticular arthritis make the
definitive diagnosis of gout. Indomethacin or colchicine is the treatment during an acute attack.
Allopurinol, probenecid, and sulfinpyrazone are used for prophylaxis against further attacks.
Allopurinol (choice A) is a xanthine oxidase inhibitor that is used as an antihyperuricemic agent
by individuals with recurrent gouty attacks. Common side effects include rash, headache, and
gastrointestinal upset.
Ceftriaxone (choice B) is the treatment of acute gonococcal arthritis. It has no role in the
treatment of gout.
Probenecid (choice D) is a uricosuric agent that increases the rate of urate excretion. It is used to
prevent gouty attacks. It may precipitate nephrolithiasis.
Sulfinpyrazone (choice E) is another uricosuric agent that increases urate excretion. It is used to
prevent gouty attacks. It, too, may precipitate nephrolithiasis.