One of the most common mistakes made in the management of gout is the addition of a urate-lowering drug during an acute attack. A decrease in uric acid level can further destabilize tophi (including microtophi, which are deposits of uric acid that are not grossly apparent), causing an exacerbation of the gout attack. The use of intravenous colchicine when the drug has recently been administered orally can result in significant bone marrow suppression. Patients with renal or hepatic insufficiency are at a particularly high risk for developing toxic levels of colchicine. Nonsteroidal anti-inflammatory drugs (NSAIDs) work well in cases of acute gout, but they should not be used in clinical settings in which a patient is at high risk for NSAID complications. In such a patient, intra-articular injection is the safest treatment and has the added benefit of a rapid decrease in pain. Aspiration alone is helpful, because removal of crystal-laden fluid can down-regulate the inflammatory process. Although joints previously involved in gout attacks have a higher likelihood of becoming infected, the presence of more than 1 affected joint makes this possibility very unlikely.
- Aspirate both knees and inject a corticosteroid solution.
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Seminars in Medical Practice
Hospital Physician Board Review Manuals
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