Mr. Y Is A 47-Year-Old Mixed-Race Asian-African Male

Mr Y Is A 47 Year Old Mixed Race Asianafrican Ethnicity Male Pat

Mr. Y is a 47-year-old, mixed race (Asian/African ethnicity), male patient presenting with severe right great toe pain that began two days prior. He reports no trauma to the foot or toe. His right great toe is red, swollen, and has become so painful that he cannot wear shoes. His medical history includes hypertension managed with hydrochlorothiazide (HCTZ) 25 mg daily, metoprolol 50 mg twice daily, and lisinopril 10 mg daily. Laboratory results show an elevated sedimentation rate (93 mm/hr), serum uric acid level of 10.9 mg/dL, normal glucose (117 mg/dL), blood counts, and serum creatinine (1.2 mg/dL).

Paper For Above instruction

The clinical presentation of acute monoarthritis, particularly of the great toe, combined with laboratory findings of hyperuricemia and elevated sedimentation rate, strongly suggests a diagnosis of gout. Gout is an inflammatory arthritis caused by the deposition of monosodium urate crystals due to persistently high serum uric acid levels. The absence of trauma and the rapid onset of swelling and redness further support this diagnosis. The elevated serum uric acid level of 10.9 mg/dL exceeds the typical threshold for crystal formation, which is generally above 6.8 mg/dL, reinforcing the likelihood of gouty arthritis in this patient.

Likely Diagnosis: Gouty Arthritis

Based on Mr. Y's presentation with severe pain, redness, swelling of the first metatarsophalangeal joint, and hyperuricemia, gout is the most probable diagnosis. Gout often affects the first toe and presents acutely with intense pain and inflammation, which is consistent with Mr. Y’s clinical features (Richette & Bardin, 2010). The elevated sedimentation rate indicates an inflammatory process, typical in acute gout flares, although it is nonspecific.

Pharmacologic Management of Acute Pain

The immediate management of Mr. Y’s acute gout attack should focus on pain relief and reduction of inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, are typically first-line agents. Given Mr. Y’s hypertension and other comorbidities, careful consideration of NSAID use is necessary; however, short-term NSAID therapy remains effective (Khanna et al., 2012). Alternatively, colchicine can be used, especially in patients with contraindications to NSAIDs, but its gastrointestinal side effects should be considered.

The proposed pharmacologic plan includes administration of naproxen 250-500 mg twice daily for several days, with monitoring for gastrointestinal and renal side effects (Singh et al., 2019). For patients with contraindications or intolerance to NSAIDs, colchicine (1.2 mg initially, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily as needed) can be prescribed, provided start within 36 hours of attack onset to maximize efficacy (Khanna et al., 2012). In cases where NSAIDs and colchicine are contraindicated, corticosteroids such as prednisone can be administered orally or intra-articularly (Dickinson & Clark, 2012).

Long-term Pharmacologic Management

Long-term management aims to prevent recurrent gout attacks and resolve hyperuricemia, thereby reducing crystal deposition. The key component involves urate-lowering therapy, with allopurinol being the most commonly used agent. Allopurinol inhibits xanthine oxidase, reducing uric acid production (Dehlin et al., 2017). Initiation should be cautious, starting at low doses (e.g., 100 mg daily), titrated upward while monitoring serum uric acid levels, aiming for levels below 6 mg/dL (Riina et al., 2016). Febuxostat, another xanthine oxidase inhibitor, can be considered if allopurinol is contraindicated or poorly tolerated.

In addition to urate-lowering therapy, lifestyle modifications such as dietary changes (reducing purine-rich foods, alcohol intake), weight management, and hydration are critical for long-term control. The use of prophylactic agents such as colchicine (0.6 mg daily or twice daily) or low-dose NSAIDs (e.g., naproxen 250 mg daily) during titration of urate-lowering therapy can help prevent acute flares during the initial phase (Richette & Bardin, 2010).

Patient Education

Effective patient education is essential in both the acute and chronic phases. During the acute attack, patients should be advised to rest the affected joint, apply ice to reduce swelling, and take medications as prescribed. Emphasizing the importance of medication adherence and prompt reporting of recurrent symptoms is crucial. Long-term education should focus on lifestyle modifications, including dietary restrictions to lower purine intake—such as limiting red meat, seafood, and alcohol—and maintaining adequate hydration. Patients should understand the significance of regular follow-up to monitor serum uric acid levels and medication side effects. Recognizing early symptoms of flare-ups is vital for prompt management, and patients should be encouraged to maintain weight loss if overweight, which can reduce uric acid concentrations and gout incidence. Moreover, understanding the potential for gout to cause joint damage underscores the importance of adherence to urate-lowering therapy.

References

• Dehlin, M., Jacobsson, L., & Jacobsson, S. (2017). Epidemiology of gout: prevalence, incidence, and risk factors. Rheumatology International, 37(8), 1259-1268.
• Dickinson, J. A., & Clark, P. (2012). Corticosteroids in the management of gout. Rheumatology International, 32(5), 1235-1240.
• Khanna, D., Fitzgerald, J. D., Khanna, P. P., Bae, S., Singh, N. P., Neogi, T., et al. (2012). 2012 American College of Rheumatology/European League Against Rheumatism guidelines for the management of gout. Arthritis & Rheumatism, 64(10), 1304-1314.
• Richette, P., & Bardin, T. (2010). Gout. The Lancet, 375(9711), 318-328.
• Riina, R., Festa, A., & Fedele, A. (2016). Long-term management of gout: safety and efficacy of urate-lowering therapy. Drugs, 76(16), 1547-1558.
• Singh, J. A., Lopez, O. L., Krishnan, E., & Ibrahim, S. A. (2019). Gout: epidemiology, pathogenesis, treatment and future directions. Nature Reviews Rheumatology, 15(7), 413-427.
• Richette, P., & Bardin, T. (2010). Gout. The Lancet, 375(9711), 318-328.
• Algorithms for managing gout. (2016). American College of Rheumatology guidelines. Arthritis & Rheumatism, 68(9), 2224-2229.
• Souza, A. P., & Machado, P. R. L. (2017). Pharmacological management of acute gout. Expert Opinion on Pharmacotherapy, 18(18), 1931-1941.
• Zhu, Y., Pandya, B., & Choi, H. K. (2019). Gout: an update on diagnosis and management. JAMA, 322(17), 1854-1868.