Podagra

Specialty: Musculoskeletal.

• acute gouty arthritis of the first metatarsophalangeal
• acute pain in the big toe

Why it occurs

• Intratissue deposition of monosodium urate microcrystals in the first metatarsophalangeal joint (chronic hyperuricemia)
• Acute dehydration or excessive intake of alcohol, red meat and seafood
• Recent initiation or dose changes of diuretic drugs (thiazides, loop diuretics)
• Start therapy with allopurinol without seizure prophylaxis
• Minor local trauma to the foot
• Chronic renal failure with decreased uric acid clearance

Initial workup

Determination of uric acid in serum (may be normal during acute crisis) | Joint puncture-aspiration (arthrochanthesis) and analysis by polarized light microscopy (demonstrates monosodium urate crystals with negative birefringence in the shape of a needle) | Joint ultrasound (shows the "double contour" sign on the articular cartilage).

Standard management

• Colchicine — 1 mg orally at the onset of symptoms, followed by 0.5 mg one hour later; maintain 0.5 mg every 12 hours during the crisis
• Indomethacin — 50 mg orally every 8 hours, decreasing the dose according to remission
• Prednisone — 20-30 mg daily orally with a reduction regimen in 5-7 days, alternative if there is a contraindication for colchicine and NSAIDs
• Allopurinol (100-300 mg once a day orally; important: DO NOT start during the acute podagra crisis, it is started after resolution under colchicine coverage).