Physical Examination and Workup
Upon physical examination, the patient is afebrile and normotensive and has a BMI of 36.81. Slight knee instability, multiple tophi, and mild pedal edema are noted.
A laboratory evaluation reveals these values:
Hemoglobin level: 13.3 g/dL (reference range, 13.2-17.1 g/dL)
White blood cell (WBC) count: 11.4 × 109 cells/L (reference range, 4-11 × 109 cells/L)
Platelet count: 291 × 109 cells/L (reference range, 150-400 × 109 cells/L)
Electrolyte levels: Normal
Creatinine level: 1.7 mg/dL (reference range, 0.9-1.3 mg/dL)
Uric acid level: 8.5 mg/dL (reference range, 4.0-8.0 mg/dL)
The tophus (similar to that illustrated in Figure 1) is aspirated. The aspiration technique is demonstrated in Figure 2. Examination of the fluid by compensated polarizing microscopy reveals negatively birefringent needle-shaped crystals (Figure 3).
His presenting colchicine dose (to prevent allopurinol-induced flares) is perceived as risky because of his elevated creatinine level. Long-term corticosteroid therapy appears disadvantageous, given its many adverse effects. A gastric-sparing nonsteroidal anti-inflammatory drug (NSAID) was deemed to be the best approach, with very close monitoring.
The patient is advised of the risks with this approach and of the critical importance of closely monitoring his kidney function. He is provided with written documentation about the risks to life and renal function. He is seen on a Friday, at the end of a locum tenens cycle. The prescribing rheumatologist will not return for 2 weeks.
As the patient's gout and related symptoms represent a chronic problem of years duration, and he had waited 9 months for his appointment, a 2-week delay in initiating treatment to ensure timely monitoring seems appropriate. He is advised not to start taking celecoxib immediately but to wait 2 weeks and start it the Sunday before the prescribing locum tenens rheumatologist is scheduled to return. He is directed to initiate celecoxib at a dosage of 100 mg every other day, with his creatinine level to be measured after the first dose, and to take the second dose only after the rheumatologist informs him that the creatinine level has not significantly increased. He is also advised to discontinue the colchicine at that time. The patient expresses some trepidation, but the rheumatologist assures him that this approach will obviate the standard clinic "regulations" and that he will be accessible during the time he is taking the medication, which is the reason for delaying its initiation.
Because of a flare, the patient waits only 1 week to start taking celecoxib. His primary care physician initiates treatment with rosuvastatin during the same week. Additionally, he takes celecoxib daily (instead of every other day, as advised), and he has his creatinine level measured only after he has taken three doses. At that time, his creatinine level is 5.9 mg/dL and he is hospitalized. His electrolyte levels are normal, his calcium level is 8.9 mg/dL (reference range, 8.5-10.5 mg/dL), and his phosphorus level is 5.8 mg/dL (reference range, 2.8-4.5 mg/dL). Urinalysis reveals microscopic hematuria (dipstick strongly positive), but red blood cells (RBCs) are not observed on microscopic examination.
The hospitalist believes that celecoxib is responsible for the elevated creatinine level, discontinues the celecoxib and nonessential medications (at least in the short term, including rosuvastatin), and serendipitously initiates a furosemide-flushing regimen. The patient develops a gouty flare in his wrist, and the hospitalist initiates a course of high-dose corticosteroids (20 mg of prednisolone every 6 hours), which is discontinued on hospital discharge. Renal function, as indicated by his creatinine level, subsequently returns to his baseline level.
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Cite this: Bruce M. Rothschild. Rheumatology Case Challenge: Statin Use and Gout in a Man Put on NSAIDs by Locum Tenens Doc - Medscape - Feb 13, 2023.