What are the options for treating patients with acute gouty arthritis postoperatively if they are unable to take oral agents?
• Indomethacin or another NSAID per nasogastric tube or suppositories per rectum. These agents may be contraindicated if the patient is at risk for surgical bleeding or gastric ulcer disease, and in the setting of known CVD or renal insufficiency. Intramuscular ketorolac 30 to 60 mg is another option if NSAID use is appropriate.
• IV colchicine has been used in the past for patients unable to take oral medicines; however, given its toxicities (bone marrow, neuromuscular, gastrointestinal), IV use of this agent should be avoided.
• Corticotropin gel (Acthar) 25 to 40 units subcutaneous injection (uncommonly used because of cost).
• Triamcinolone acetonide 40 to 60 mg/day intramuscularly for one to two doses. This may be the safest option in many cases.
• Methylprednisolone 20–60 mg IV daily for several days, and then replace with oral prednisone, tapering when appropriate.
• Corticosteroid preparation injected into the joint (if you are sure it is not infected).