#489 Live from SHM #Converge2025 Rheumatology for the Hospitalist

June 30, 2025 | By Meredith Trubitt

Audio

Video

Transcript available via YouTube

Take the ache out of those joint aches!

Learn about inpatient diagnosis and management of crystalline arthropathies as well as a brief conversation about those rheumatology NOS cases. We’re joined by Dr. Kimberly Trotter, MD (University of Chicago). 

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Show Segments

• Intro
• Rapid fire questions/Picks of the Week
• Case 1
• Differential Diagnosis of arthropathy
• Risk factors for Gout
• Diagnostic Evaluation 
• Acute Treatments 
• Long-term Treatments
• Transitions of Care for Crystalline Arthropathy
• Case 2
• History and Physical Exam
• Diagnostic Work up
• Treatment
• Outro

Disclosures

Dr. Trotter  reports financial relationship with GSK-Membership on Advisory Committee. The Curbsiders report no relevant financial disclosures.

Rheumatology for the Hospitalist Pearls

1. Colchicine is a great option for acute gout flare, but will only work if onset of symptoms has been within 36 hours. 
2. Preset steroid tapers (i.e. solu-medrol dose packs)  are not a good option because the steroid should not be tapered until response to therapy has been achieved. If started on a preset pack they can have rebound flare/symptoms. 
3. Allopurinol hypersensitivity syndrome can present in a variety of rashes as well as be accompanied by systemic symptoms such as fevers, elevated eosinophils, and kidney dysfunction, so it is important to alert patients to monitor for cutaneous symptoms when starting allopurinol. 
4. In order to prevent gout flares, the uric acid level needs to be < 6 mg/dL, but often reference ranges will have a normal range through 8-8.5 mg/dL. 
5. Post infectious joint or muscle pains/weakness can persist up to 6 weeks after acute infection.

Rheumatology for the Hospitalist

Crystalline Arthropathies 

Definitions and Differential Diagnosis

The differential diagnoses for a painful joint should remain broad and outside of crystalline arthropathies, can include osteoarthritis, trauma, and infection (Dalbeth, 2021). It is worth noting that with osteoarthritis, it is typically not as severe as pain that is seen  with the crystalline arthropathies, and typically not associated with  significant swelling or warmth of the joint. 

The history and physical exam findings that would point toward a crystalline arthropathy are sudden and severe onset of pain associated with significant decrease in range of motion. If the affected joint is the first big toe, then this is called podagra, and is particularly characteristic of gout. 

Risk Factors

Noteworthy modifiable risk factors for the development of gout include: cardiovascular disease, kidney disease, dietary factors, and medications that alter urate balance. The only medications which the guideline comments on are stopping hydrochlorothiazide and starting losartan; however, both of these are with very low certainty of evidence and should only be done if truly feasible for the patients overall care and considerations of co-morbidities (FitzGerald, 2020). 

Diagnostic Evaluation

The gold standard for the diagnosis of crystalline arthropathy is an arthrocentesis, and Dr. Trotter recommends that if it is a patient’s initial presentation that they should undergo one. If it is a recurrent episode and similar to prior flares, and diagnosis has been confirmed with arthrocentesis previously, it is not necessary to repeat on each subsequent encounter (Dalbeth, 2021). However, if the presentation is in a different joint, it is likely beneficial to repeat the arthrocentesis for confirmation of diagnosis. 

After obtaining arthrocentesis, the sample can be looked at under a polarizing microscope. Gout will show monosodium urate crystals which are needle-shaped, and negatively birefringent (yellow in parallel, and blue in perpendicular field) (Dalbeth, 2021). Calcium pyrophosphate deposition disease (CPPD) will show calcium pyrophosphate dihydrate crystals which are rhomboid or rectangularly shaped and will be positively birefringent (blue in parallel, and yellow in perpendicular field) .

Uric acid levels cannot be used during the acute flare for diagnostic purposes, as they may be artificially low during the flare. It will also not be helpful if it is CPPD. However, Dr. Trotter explains that it can be helpful to obtain a baseline level at time of initial acute flare to help guide long-term management as the levels are trended. 

Imaging may be considered if there is a concern for trauma; however, if  there is high concern for crystalline arthropathy then imaging is unlikely to provide meaningful diagnostic information in the acute setting especially if this is the first gout flare. For patients with long-standing gout, XR may show erosions or other changes consistent with gout.  

Acute Treatments

NSAIDs: remain first line therapy for acute crystalline arthropathy (FitzGerald, 2020). The same limitations exist such as being cognizant of use in chronic kidney disease and heart disease. Dr. Trotter reminds us that any NSAID can be used, but typically requires higher doses (Durme, 2021). 

Colchicine: also is first line therapy (FitzGerald, 2020), but is only efficacious if started within 36 hours of onset of symptoms. If it is after 36 hours, it is unlikely to be effective. If the patient has normal kidney function, can give the 1.2 mg followed by 0.6 mg one hour later. It is then recommended to continue 0.6 mg daily or twice a day until 1-2 days after symptoms resolve. Dose must be adjusted for kidney disease. The lowest effective dose is recommended (FitzGerald, 2020). Lastly, if the patient is already on colchicine for maintenance therapy, it is unlikely to be effective at a different dose during an acute flare. 

Intra-articular steroids: can utilize this as an option if NSAIDs and colchicine are not an option, and the flare is limited to no more than 1-2 joints that would require injection (FitzGerald, 2020). Notably, the big toe is a painful joint to inject so sometimes this may not be well tolerated for a patient. 

Oral steroids: also first line therapy if NSAIDs and colchicine are not an option and multiple joints affected (FitzGerald, 2020). It is reasonable to start at 40 mg daily or an equivalent dose. The goal is to continue at 40 mg until the patient reports improvement in symptoms. After 1-2 days with improvement, the steroids can be tapered by 10 mg increments over 3 days usually, with the goal that by the time the patient is on the 10 mg dose they ideally will be pain free. This pattern is worth noting, as it explains why pre-packaged steroids are not usually efficacious, as pre-packaged courses are often too short to obtain adequate control of inflammation. 

IL-1 antagonists: these medications are reserved for patients who are unable to tolerate any of the above listed standard of care medications or significantly refractory disease. For Anakinra, Dr. Trotter says that after receiving 1-2 days of therapy, usually can transition back to standard of care. For canakinumab, it is a single dose, but often not used due to significantly higher cost. 

Long-term Treatments

If it is a patient’s first flare, long-term therapies can often be deferred to the outpatient setting. However, conditions such as chronic kidney disease, tophi, or erosions on exam may prompt early initiation of urate lowering therapy (FitzGerald, 2020). Dr. Trotter recommends starting this therapy closer to time to discharge to ensure acute therapies are adequately controlling symptoms. 

Allopurinol: is a xanthine oxidase inhibitor and is first line therapy unless prior allergic reaction (FitzGerald, 2020). If normal kidney function, typically start at 100 mg/day, and recommend increasing dose until goal uric acid levels are reached. If the patient has CKD stage 3b or higher, then the recommended starting dose is 50 mg/day and to increase over time from this starting point. The max dose of allopurinol is 300 mg / day so it can take substantial time to reach therapeutic dosing. 

Additionally, it is important to be mindful of allopurinol hypersensitivity syndrome which includes Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms. Patients will typically present with exanthem, eosinophilia, and renal and/or liver impairment. It is recommended to stop the offending agent immediately and provide supportive care (Yaseen, 2023). The HLA-B*5801 allele is associated with higher risk of allopurinol hypersensitivity syndrome most commonly in patients of Southeast Asian descent and for African Americans, so in these sub-populations it is recommended to check this allele prior to initiating allopurinol. It is not recommended to check in other sub-populations (FitzGerald, 2020). 

Febuxostat: is a xanthine oxidase inhibitor and is used if the patient cannot tolerate allopurinol or if the patient is not getting to goal urate level with allopurinol. Notably it only comes in two doses (40 mg and 80 mg), and so Dr. Trotter reminds us it is often faster to get to the goal on febuxostat than on allopurinol. 

Pegloticase: is a modified urate oxidase so it can break down uric acid to be excreted in urine. It is reserved for severe gout, specifically patients with tophi, erosions, or who have been unable to get to goal uric acid goal. It is administered intravenously every 2 weeks, and is more costly than allopurinol and febuxostat. Additionally, it cannot be used in patients who have G6PD deficiency. 

Lastly, for CPPD there are not great long-term therapies for prevention of CPPD. Often patients may present with a single CPPD flare in their life and would not warrant further therapy. However, in patients who have recurrent flares, can trial colchicine as long-term therapy, but results can be variable. 

Transitions of Care

Medications: ensure they have adequate supply of the acute therapy at time of discharge. If the plan was to start urate lowering therapy, also ensure they have adequate supply of this medication until their follow up appointment. 

Follow-up appointments: primary care can usually follow up; however, if the patient has refractory disease, then recommend arranging rheumatology follow up. 

Labs: after the flare is completely resolved (about 2-4 weeks), it is time to get uric acid level. Goal level is < 6 mg/dL (FitzGerald, 2020). 

Medication Reconciliation: if a patient was previously on hydrochlorothiazide, consider discontinuing it, if a feasible alternative exists (FitzGerald, 2020). 

Counselling: recommend reducing alcohol consumption, limiting purine intake (red meat, shellfish), limiting high fructose corn syrup, and using a weight loss program (FitzGerald, 2020).

Rheumatology NOS 

For patients admitted to the hospital with weakness, myalgias, with broad differential including infectious and autoimmune etiologies, pay attention to time course. If less than 6 weeks, this favors an infectious etiology, and sometimes patients need to be supported through this. If they have tried over the counter antiinflammatories without improvement and infectious work-up is negative, and weakness is debilitating, then it may be reasonable to consider low dose steroids (15-20 mg) for a short course until improvement is seen (expert opinion). Ensure adequate work up such as ESR/CRP and CPK has been done and that these do not suggest an autoimmune etiology. If in doubt, phone your friendly neighborhood rheumatologist to coordinate further work-up. 

Links

1. George Benson at Encore Theater at Wynn
2. Kelly Clarkson at the Colosseum Caesars Palace
3. Crossroads Kitchen at Resorts World

Goal

Listeners will develop a framework to approach the prevention, evaluation, and management of gout in the hospitalized patient.

Learning objectives

After listening to this episode listeners will…  

1. Define gout and pseudogout.
2. Identify the appropriate acute and chronic gout management in specific patient populations.
3. Recognize clinical signs and symptoms of allopurinol hypersensitivity syndrome. 

Citation

Trubitt M, Amin M, Coleman C, Trotter K, Williams PN, Watto MF. “#489 Live from SHM #Converge2025 Rheumatology for the Hospitalist”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date June 30, 2025.