The correct answer is E. Steroids, especially intraarticular steroids, are very effective when NSAIDs (which are the treatment of choice for gout) are contraindicated. In this patient, chronic renal insufficiency is a relative contraindication to NSAID use. Therefore, intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.
Allopurinol (choice A) is a xanthine oxidase inhibitor, which is an effective therapy for hyperuricemia. Allopurinol has no role in the treatment of acute gout since it may cause the mobilization of tophi, thereby causing increased pain. It is useful to keep the uric acid level within normal limits and should be started after the acute attack has resolved to prevent recurrences. Do not forget to keep a patient's comorbidity in mind prior to prescribing treatments. This patient would likely benefit from decreasing his alcohol intake and changing his antihypertensive medication to one that will not increase uric acid levels.
Aspirin (choice B), especially low-dose aspirin, may increase uric acid levels by inhibiting renal excretion of uric acid. Aspirin is therefore not indicated in the treatment of gout.
Colchicine (choice C) is an effective treatment for gout but there are several side effects associated with its use. It is often associated with severe GI side effects. At high doses (especially IV therapy), bone marrow suppression can occur. Liver disease and kidney disease may increase colchicine levels and should be avoided in these patients if possible.
NSAIDs, such as indomethacin, (choice D) are the treatment of choice for most patients with gout. Typically, treatment begins with high dose NSAIDs, which are rapidly tapered. This patient has kidney disease and therefore should not be given high-dose NSAIDs.
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