The Acute Gouty Arthritis Attack

So, you wake up one morning with pain in your big toe (podagra). You inspect it only to find your toe is swollen, red, and hurts like the dickens. Welcome to your first acute gouty arthritis attack.

Gouty arthritis is a condition of metabolism, whereby your kidneys are not excreting the build up of uric acid in your blood. You didn't know it, but your uric acid levels have been high for years, and now urate crystals have deposited in the joint of your big toe causing inflammation. You also notice a large lump on the side of your toe. This is called tophi. The urate crystals have not only settled in the toe joint, but has taken up residence in the soft tissue surrounding the joint.

The pain is becoming excruciating, throbbing with each beat of your heart, and you are not sure how much more of this you can stand. Time to call the doctor.

You have called your doctor and explained the details of how you woke up this morning with this awful pain, swelling, and tenderness in your big toe. You tell him that you don't remember bumping it, and things were just fine when you went to bed last night, yet you wake up to this nightmare. The doctor is reluctant to make a diagnosis over the phone and has made arrangements for you to come into his office.

History and testing:

You arrive at the doctor's office, limping so as not to put any pressure on your aching toe. The nurse greets you and shows you to the examination room where you wait in pain for the doctor to come in. Finally he enters the room after what seems like an eternity, but its only been about 15 minutes.

"What's wrong Joe?" he asks.

"Well doc, like I says on the phone, I wake up and my toe is all swollen and purplish looking with no reason for it at all. I'm kinda worried." Am I gonna die?" Joe replies fearfully with his eyebrows sticking up in the air like two football posts saluting the sky.

"Yes, Joe, I'm afraid you are going to die, but it won't be from that toe. Looks like you have a good case of gouty arthritis, but I will need to take some tests to make sure. I will need some blood and urine. I will also need to test the fluid that is making your toe swell."

Joe is asked about any family history, if anyone in his family has ever had symptoms such as his. Joe doesn't know if anyone in his immediate family has had this, not that he can remember anyway. The doctor is pretty sure what Joe's problem is, but the only way to make sure is to perform the following tests:

Complete Blood Count and Differential (CBC & Diff):

This test will check for a complete count of the type of blood cells. If the doctor is correct in his preliminary analysis, he's going to find increased white blood cells (WBC), leukocytes, and neutrophils, as well as a host of other cells and debris that would indicate that there is inflammation going on inside that toe. He will also find a high level of uric acid in Joe's blood, which would be a tell tale sign that Joe probably is having an acute gouty arthritis attack.

Urinalysis:

The doc will take a specimen of Joe's urine. what is he checking for? He is looking for levels of uric acid. Low levels of uric acid means Joe's kidney's are not excreting uric acid properly, which would coincide with the high level of uric acid in Joe's blood test.

Needle Aspiration Biopsy:

The doctor will insert a needle into the joint of Joe's toe and draw out some of the fluid for testing. In this test, the doctor may find needle-like objects called monosodium urate crystals, caused by the high level of uric acid in Joe's blood. These crystals are what could be causing the pain in Joe's toe.

Because the doctor has his own lab on premises, he will not have to send Joe's tests to another lab to get the results, and Joe won't have to wait to find out what is wrong with his hurting-more-by-the-minute swollen big toe.

Treatment:

Well, the verdict is in. Joe is having an acute gouty arthritis attack. Joe's uric acid level is extremely high at over 10 mg/dL (normal levels for a man is 3.4-7.0 mg/dL. Different labs differ in these numbers) Joe also has other risk factors for gout:

• Joe is 25 lb overweight


• Enjoys a beer or two every day


• Has diabetes

Beer is high in purines and is contributing to the high uric acid level. Also, Joe is diabetic. His blood sugars have been out of whack lately, but that is because he isn't taking proper care of himself. A complication of diabetes is poor circulation, which can cause damage to the kidneys. For this reason, the doctor has ordered a kidney function test for Joe.

To treat Joe's pain the doctor has a choice of medications he can choose from. These medications include:

Over-the-counter NSAIDs:

• Low-dose Ibuprofen (Motrin IB, Advil, Nuprin)


• Naproxen (Aleve)


• Ketoprofen (Actron, Orudis KT)

Prescription NSAIDs:

• Ibuprofen (Motrin)


• Naproxen (Naprosyn, Anaprox)


• Flurbiprofen (Ansaid)


• Diclofenac (Voltaren)


• Tolmetin (Tolectin)


• Ketoprofen (Orudis, Oruvail)


• Dexibuprofen (Seractil)


• Indomethacin (Indocin)

Usually with the first gouty arthritis attack, preventative medication is not ordered. But due to Joe's other underlying condition of diabetes and being overweight, the doctor prescribes what is called prophylactic medications to prevent another attack. These medications include colchicine and allopurinal, but he is not to begin taking these meds until the present attack has resolved.

In the meantime, the doctor gives Joe an injection of corticosteriods in the affected joint to take care of the pain. Corticisteroids include triamcinolone and prednisone, which will help with Joe's pain and reduce inflammation. In addition to this, Joe is instructed on what he can do to prevent further attacks which include:

• Drinking lots of water


• Avoiding acohol


• Losing weight


• Reduce stress


• Avoid, or eat in moderation foods that are high in purine, as well as a list of foods that are low in purines.

Joe is now a happy camper. His pain has been reduced, he has his prescriptions for pain medications to get filled, and now he is going home for some much needed rest. This has been one heck of a day. Rest easy, Joe.

by Barb Hicks, RN