We tapped the joints that day and found gout crystals. Now we had our dilemma. How should we treat this patient with enterococcal endocarditis ( I was out of town yesterday and misremembered the organism) and a creatinine of 1.6?
What drug would you use for this relatively severe gout attack? I do believe the fever was the initial presentation of this attack.
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I would avoid NSAIDs due to his diminished kidney function. How about colchicine dose-adjusted to his GFR? May also reluctantly consider intra-articular steroid injection.
I’ve been surprised at how often we see this pop up in hospitalized patients.
No way I’d want to bang his kidneys with NSAIDs. He’s probably on gent anyway.
I worry about the toxicity of conchicine with his creatinine as high as it is. Best bet might be intra-articular or even systemic steroids if you could get by with a short course.
As a nephrologist, I am always pleased to see such concern for the beans. I agree that NSAIDs (and COX2i for that matter) are a big no-no. I do feel however, concerns about Colchicine use in CKD are often over-blown. I would start with colchicine too then intrarticular steroids if no benefit (and/or diarrhea).
Despite the infection I would treat him with a 7-10 day course of prednisone. It is polyarticular and severe. Colchicine will not work. Would start with 40 mg qd x 2 days and then taper.
We all agree with no NSAIDS. Colchicine with kidney disease can be OK with prophylactic doses but for acute gout you need big doses and the therapeutic window becomes very small. The typical scenario is diarrhea after a few doses which lasts a longer time because of the renal failure. Half the time the nursing and housestaff don’t recognize the problem as a side effect and the colchicine is continued while clostridium studies are done or antibiotics changed. Meanwhile your rehab bed slips away. Intra-articular injections are generally good in renal failure but less so if infection is a concern because most of the IA preparations are depo-drugs which stay in the joint for prolonged periods. Since the patient has been afebrile for a while and the antibiotics will be continued, I’d give systemic steroids but gout only needs 15-20mg and can be tapered down quite quickly.
I disagree with 3+ speckled. Most guidelines suggest starting with 40 mg of prednisone for a gouty flare.
Oops. And there it is. I suppose my quesion in “Oops” has already been addressed
Sure 40 mg will work better than 20 for the occasional resistant case, but for the average hospitalized patient who is often diabetic or demented, infected, heart failured, stomach ulcered or polypharmed, less is better and in almost all cases, 15-20 will do the job.
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