Wow. That’s the first word that came to my mind as I read the responses to my recent “Rheuminations” article about a difficult gout case. The point of my article was that, even with a condition as seemingly simple as gout, complexity intrudes and can wreak havoc with even the established approach to patient care.
I felt a “wow” quality for several reasons. First and foremost, I was excited that readers took the time to write in and share their opinions. Writing is a lonesome calling and, while I send a blizzard of words into the world on printed pages and the electronic beams of cyberspace, until I get a reply, I live in a vacuum.
Via countless e-mails, I hear regularly from Medscape, lonesome Olga from the frozen steppes of Siberia, and a host of companies hawking products to soup up my ELISAs. While there is some comfort in receiving any email—it is a sign that I am alive and someone thinks I am of value—I really want to hear from you, my readers. Did you like what I wrote? Did my words connect? Did I make sense? I am therefore thrilled by the volume of responses.
To the contributors whose replies are printed on page 8, I say a sincere and heartfelt “thank you” for reading and writing.
From what I have been reading about the looming disaster on healthcare financing, we should have a “pray-for-performance” initiative.
“Best” Treatment Choice?
The second reason I felt a “wow” quality is the recognition that there are a slew of ways to treat gout in the patient I described. To eliminate any suspense, my preference would be a brief course of glucocorticoids. My preference here is most certainly not evidence-based, primarily because there is no evidence. Rather, I like a course of prednisone because it fits my treatment philosophy (not invasive if I don’t have to be) and, on the occasions where I have had a similar clinical situation, it has worked very well.
Could I have justified a course of adrenocorticotropic hormone (ACTH)? Absolutely. Intra-articular steroids? Sure. Intravenous colchicine? Maybe or maybe not. On the basis of science, I think colchicine would be a great choice—it stops the inflammasome in its tracks—but the literature describes nastiness with this drug. I do not want to ravage the bone marrow for a joint problem that will likely go away by itself.