Exploring the Use of Intra-articular Ketorolac Injection for Acute Gout in the Knee

Case Diagnosis: The use of intra-articular ketorolac injection for acute gout over corticosteroids

Case Description or Program Description: 54-year-old male with acute stroke presented with acute right knee pain at the stroke inpatient rehabilitation hospital. On physical examination patient had a right swollen knee. The patient had 10/10 pain with manual muscle testing of the knee and pain with range of motion. The patient also had difficulty with therapy due to the knee pain. The right knee was aspirated and the synovial fluid analysis showed the presence monourate sodium crystals.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: The patient was diagnosed with acute gout of the right knee. The patient has no history of gout and this was a new diagnosis. 60 mg of ketorolac and 2% lidocaine were intra-articularly injected to the patient’s right knee. Within 24 hours the patient’s pain improved to a 0/10 pain on the visual analog scale. Patient was able to participate in daily therapy without pain and was discharge home after two weeks. The patient only received one dose of intra-articular ketorolac injection.

Discussion (relevance): Acute gout flares are characterized by rapid onset of severe pain and common in the foot and knee. Common treatment of acute gout includes oral corticosteroids, nonsteroid anti-inflammatory drugs, and colchicine. Intra-articular injections with corticosteroids are also used for management of acute gout. Unfortunately, these medications come with side effects and cautioned with patient with diabetes, kidney disease, and peptic ulcer. Intramuscular injections with ketorolac have been published with effectiveness, however, intra-articular injection administration of ketorolac has never been reported. To our knowledge this is the first reported case to demonstrate effectiveness and tolerance of intra-articular ketorolac for acute gout. This administration into the joint also minimizes the systemic effect of ketorolac.

Conclusions: This is the first reported case, to our knowledge, of intra-articular ketorolac knee injection for the treatment of acute gout.