Rosen & Barkin's 5-Minute Emergency Medicine Consult (306 page)

• Arthrocentesis
  
• Aspiration of tophi
  

• Infectious arthritis
  
• Trauma
  
• Osteoarthritis
  
• Reactive arthritis
  
• Miscellaneous crystalline arthritis
  
• Aseptic necrosis
  
• Rheumatoid arthritis
  
• Systemic lupus erythematosus
  
• Sickle cell
  
• Osteomyelitis
  
• Psoriatic arthritis
  

TREATMENT

• Relieve pain.
  
• Rule out infectious cause.
  

• NSAIDs are 1st-line treatment.
  
• If NSAIDS ineffective or contraindicated:
  
  • Steroids (oral, intravascular, IM, intra-articular)
    
  • Colchicine (limited by toxicity)
    
• Joint aspiration
  
• Avoid aspirin
  
• Reduction of hyperuricemia and long-term management of gout and pseudogout are not within the usual scope of ED care:
  
  • Careful withdrawal of gout-producing agent
    
  • Uricosurics (e.g., probenecid, sulfinpyrazone)
    
  • Allopurinol to reduce uric acid synthesis
    
  • Increased fluid intake and urine alkalization to prevent renal stones
    
  • Long-term colchicine or NSAIDs prophylactically
    

• Anakinra: 100 mg SQ QD:
  
  • Off label use for chronic, treatment refractory gout or pseudogout and with renal failure
    
• Allopurinol: 100 mg PO QD, increased weekly to max. 800 mg QD:
  
  • Start 1–2 wk after attack has resolved
    
  • Adjust for kidney disease
    
  • Discontinue with rash or fever
    
  • Treatment of choice with uric acid kidney stones
    
  • Doses >400 mg should be taken in divided doses
    
• Colchicine: 1.2 mg PO upon gout flare followed by 0.6 mg 1 hr later:
  
  • Can cause bone marrow suppression at high doses
    
  • Not dialyzable
    
  • Long-term use may cause myopathy.
    
  • Adjust dose for liver or kidney disease.
    
  • Does not prevent monosodium urate deposition or joint damage of chronic gout
    
• Corticosteroids:
  
  • Corticotropin: 40 units IM, q8h, up to 2 doses
    
  • Methylprednisolone: 40 mg (peds: 1–2 mg/kg) IM or IV QD for 3–4 days
    
  • Prednisone: 40 mg (peds: 1–2 mg/kg) PO QD for 3–4 days; taper over 7–14 days
    
  • Triamcinolone: 10–40 mg + dexamethasone 2–10 mg intra-articularly
    
• Febuxostat: 40–80 mg QD:
  
  • Give with NSAID or colchicine when 1st started
    
  • Inhibits urate production
    
  • Safe for mild or moderate kidney disease
    
• NSAIDs in maximal doses initially for 3 days, then taper over 4 days:
  
  • Ibuprofen: 800 mg (peds: 10 mg/kg) PO QID
    
  • Indomethacin: 25–50 mg PO TOD–QID (peds: 2 mg/kg/d TID–QID;
    not
    for children <14 yr old)
    
  • Ketorolac: 15–30 mg IM/IV in ED, may repeat for 1 dose (peds: 1 mg/kg to max. 30 mg IM or 0.5 mg/kg to max. 15 mg IV) IM:
    
  • Naproxen: 500 mg PO TID (peds: 5 mg/kg PO BID)
    
  • Sulindac: 200 mg PO TID
    
• Pegloticase: 8 mg IV over 2+ hr q2wk
  
  • For gout refractory to conventional treatment
    
  • Premedicate with antihistamine and steroids
    
  • Associated with anaphylaxis
    
  • Stop if uric acid increases to >6 mg/dL
    
  • Contraindicated with G6PD deficiency
    
• Probenecid: 250–500 mg PO q12h, max. 3 g QD:
  
  • Promotes excretion of uric acid
    
  • Not effective or less effective with renal disease or aspirin or diuretic use
    
  • Relatively contraindicated with presence of uric acid kidney stones
    
• Rilonacept: 2 × 160 mg (2 × 2 mL) SC injected into 2 different sites on the same day, then 160 mg (1 × 2 mL) SC every week –Off label use for acute gout or prophylaxis
  
  • Given during initiation of urate-lowering therapy
    
• Sulfinpyrazone: 200–400 mg PO in divided doses BID with food, maintenance dose 400 mg in divided doses BID, max. 800 mg QD
  

NSAIDs may worsen renal function, fluid retention, gastropathy, hepatotoxicity, and cognitive function, particularly in the elderly.

Gout not usually seen in children, although possible during chemotherapy treatment for cancer.

FOLLOW-UP

• Suspected infectious arthritis
  
• Acute renal failure
  
• Intractable pain
  

• No evidence of infection
  
• Adequate pain relief
  

• Septic arthritis
  
• Renal failure
  

• Rheumatology follow-up in severe or difficult to control cases
  
• Renal follow-up if renal insufficiency is present
  
• Urology follow-up if uric acid stones are present
  
• Orthopedic follow-up in cases of septic arthritis or significant joint damage
  
• Advise patient to follow a low-purine diet.
  

• Septic arthritis can occur simultaneously with an acute gout attack.
  
• NSAIDs are 1st-line treatment if tolerated.
  
• Attacks generally tend to be self-limited.
  
• Gout and pseudogout can lead to bony and cartilaginous damage.
  

• Crittenden DB, Pillinger MH. New therapies for gout.
  Annu Rev Med.
  2013;64:325–337.
  
• Laubscher T, Dumont Z, Regier L, et al. Taking the stress out of managing gout.
  Can Fam Physician
  . 2009;55:1209–1212.
  
• Smith HS, Bracken D, Smith JM. Gout: Current insights and future perspectives.
  J Pain
  . 2011;12:1113–1129.
  
• Terkeltaub R. Update on gout: New therapeutic strategies and options.
  Nat Rev Rheumatol
  . 2010;6:30–38.
  
• Yanai H, Yoshida H, Tada N. Clinical, radiologic, and biochemical characteristics in patients with diseases mimicking polymyalgia rheumatica.
  Clin Interv Aging
  . 2009;4:391–395.
  

See Also (Topic, Algorithm, Electronic Media Element)

www.Epocrates.com

CODES

• 274.00 Gouty arthropathy, unspecified
  
• 274.9 Gout, unspecified
  
• 712.30 Chondrocalcinosis, unspecified, site unspecified
  

BASICS

• A significant decrease in the number of granulocytes in the peripheral blood.
  
• 3 classes of granulocytes:
  
  • Neutrophils or polymorphonuclear (PMN) cells and bands
    
  • Eosinophils
    
  • Basophils
    
• As PMN cells predominate, the term neutropenia is often used interchangeably with granulocytopenia, as almost all granulocytopenic patients are neutropenic.
  
• Granulocytes are a key component of the innate immune system.
  
• The clinical risks resulting from granulocytopenia are best defined by the level of the absolute neutrophil count (ANC):
  
  • ANC = WBC × percentage (PMN + bands)
    
  • Modern automated instruments often calculate and report ANC.
    
• Neutropenia: ANC <1,500 cells/mm
  ³
  :
  
  • Mild: Between 1,000 and 1,500
    
  • Moderate: Between 500 and 1,000
    
  • Severe: <500
    
  • Agranulocytosis: <100
    
  • Patients with a count <1,000 that has recently or rapidly fallen are at greater risk for infection than those with a count <500 but rising.
    
  • Patients with myelodysplastic syndromes should be considered granulocytopenic with higher counts because of defective neutrophils.
    
• 4 basic mechanisms cause granulocytopenia:
  
  • Decreased production
    
  • Ineffective granulopoiesis
    
  • Shift of circulating PMN cells to vascular endothelium
    
  • Enhanced peripheral destruction.
    
• Mortality of fever and neutropenia is as high as 50% if untreated:
  
  • Mortality correlates with the duration and severity of the neutropenia and the time elapsed until the 1st dose of antibiotics.
    
• 21% of patients with cancer and neutropenic fever develop serious complications.