A 65-year-old man had a 10-year history of deformity of the hands, pain, and nodules on the fingers. His serum uric acid level was 9 mg/dL. The suspected diagnosis of chronic tophaceous gout was confirmed by the finding of birefringent monosodium urate needle-shaped crystals in the joint fluid and the patient's significant response to colchicine within 12 to 24 hours of the start of therapy.
Dr Sunita Puri of Decatur, Ala, comments that the first metacarpophalangeal joint of the great toe is commonly involved, but other joints may be affected as well. In this patient, small joints of the fingers and feet were affected.
If repeated attacks of acute gout are inadequately treated, chronic tophaceous arthritis can develop. Tophi may arise on the external ear, elbow, hands, and feet. The large joints, such as the shoulder and the hip, are usually spared. Patients with clinically evident tophaceous deposits are at high risk for joint damage and renal stones.
For acute attacks, NSAIDs and colchicine are used. Oral colchicine is given at a dosage of 0.5 to 1.2 mg every 1 to 2 hours until the patient responds or side effectsSMQ-8212-SMQincluding nausea, vomiting, and diarrheaSMQ-8212-SMQdevelop. To avoid GI adverse effects, colchicine may be given intravenously, 1 to 2 mg with 20 mL of sodium chloride slowly over 5 minutes. Do not exceed 4 mg in 24 hours.
Colchicine, 0.5 or 0.6 mg twice daily, may be used prophylactically. To lower serum uric acid level, prescribe allopurinol, 200 to 300 mg/d. In patients who take allopurinol, rash followed by a potentially severe total hypersensitivity reaction may develop. If rash arises, discontinue the drug immediately. Probenecid or sulfinpyrazone are alternatives to allopurinol.
Initially, this patient was given NSAIDs and colchicine. After the acute attack was treated, probenecid was prescribed and the patient was followed closely. He is asymptomatic, and his serum uric acid level is 6.5 mg/dL.