doc_clotaire
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A 77-year-old man with comes to the emergency department with left knee swelling and intense pain for 7 hours. He has a history of hypertension, treated with hydrochlorothiazide, alcohol abuse, and chronic renal insufficiency with a baseline creatinine of 3.4 mg/dL. His temperature is 37.3 C (99.2 F). Physical examination shows an erythematous, warm, tender knee. The remainder of the examination is unremarkable. You aspirate fluid from his knee and send it for evaluation. The results come back as "negatively birefringent crystals." The most appropriate management at this time is to administer
A . Allopurinol
B. aspirin
C. colchicine
D. indomethacin
E. intraarticular steroids
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| hero
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e?
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| dr.wad
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D
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| rain-maine
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D absolutely
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| farnsworth
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E
rationale: the patient suffers from gout and negatively renal insufficiency (compensated state). NSAIDs may aggravate the latter condition.
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| deja_vu
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C
NSAIDS contraindicated. so next choice
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| farnsworth
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colchicine is contraindicated in severe kidney impairment (CrCl < 10mL/min)
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| simi
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E- Intraarticular or oral steroids in elderly pts who cannot tolerate NSAIDS N Colchicine.
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| dr_arc
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E - intraarticular steroids
NSAIDS usu the first choice in a heatlhy younger person
Colchicine may be given if pt has C/I to NSAIDS esp GIbleed history.
renal failure - bith NSAIDS and colchicine C/I
next bes thing for a pt with c/I to both is steroids either oral or intraarticular, usu intraarticular in an ill pt.
Aspirin is never never given for acute gout
Allopurinol never during acute phase will cause change in uric acid levels and further worsening of gout
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| aspire
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E ? no allopurinol and colchicine due to reasons mentioned above. No indomethacin as he has renal impairment and no aspirin as he is prone to peptic ulcer bleed due to alcohol abuse.
So, intraarticular steroids...
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| deja_vu
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i apologize. should be E:steroids. No colchicine for bad kidney.
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| farnsworth
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no need to apologize! this board is for discussing those tricky questions (and learning from each other)
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| pr20
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E.Intraarticular steroids.
NSAIDS and Colchicine should be avoided in patients with renal and hepatic dysfunction.
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| WaqasQureshi
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intraarticular steroids
indicated in
old patients, renal failure
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| doc_clotaire
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Good call farnsworth 
Explanation:
The correct answer is E.
Steroids, especially intraarticular steroids, are very effective when NSAIDs (which are the treatment of choice for gout) are contraindicated. In this patient, chronic renal insufficiency is a relative contraindication to NSAID use. Therefore, intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.
Allopurinol (choice A) is a xanthine oxidase inhibitor, which is an effective therapy for hyperuricemia. Allopurinol has no role in the treatment of acute gout since it may cause the mobilization of tophi, thereby causing increased pain. It is useful to keep the uric acid level within normal limits and should be started after the acute attack has resolved to prevent recurrences. Do not forget to keep a patient's comorbidity in mind prior to prescribing treatments. This patient would likely benefit from decreasing his alcohol intake and changing his antihypertensive medication to one that will not increase uric acid levels. Aspirin (choice B), especially low-dose aspirin, may increase uric acid levels by inhibiting renal excretion of uric acid. Aspirin is therefore not indicated in the treatment of gout. Colchicine (choice C) is an effective treatment for gout but there are several side effects associated with its use. It is often associated with severe GI side effects. At high doses (especially IV therapy), bone marrow suppression can occur. Liver disease and kidney disease may increase colchicine levels and should be avoided in these patients if possible.
NSAIDs, such as indomethacin, (choice D) are the treatment of choice for most patients with gout. Typically, treatment begins with high dose NSAIDs, which are rapidly tapered. This patient has kidney disease and therefore should not be given high-dose NSAIDs
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