(Kiosk 1) Acute Pain Secondary to Debilitating Polyarticular Gout on the Inpatient Rehabilitation Unit: A Case Report

Case Diagnosis: 51-year-old male with polyarticular gout

Case Description: The patient presented to inpatient rehabilitation with severe pain and mobility limitations secondary to refractory polyarticular gout. Multimodal pain regimen was escalated, but he still required total assistance across all therapy disciplines. MRI confirmed bony erosions with edema diffusely in bilateral joints. Consulting rheumatologists recommended treatment with anakinra, steroids, colchicine, and allopurinol, but deferred initiation of uricase enzymes. Physiatry advocated for pegloticase on the inpatient unit to expedite functional recovery, garnering a first-time approval from hospital administration.

Discussion: This demonstrates the importance of managing pain to improve function as a physiatrist by treating the underlying pain generator, in this case refractory gout. Patient advocacy should be at the forefront of the mind of a physiatrist with the goal of improving quality of life while on the unit, which includes the challenging tasks of navigating complex insurance and hospital systems. Early pegloticase initiation prevented further gout flares and facilitated return to functional independence within two months of discharge.

Setting: Tertiary care inpatient rehabilitation hospital

Assessment/Results: The patient initially required total assistance across therapy disciplines and was non-ambulatory. After two weeks, he required moderate assistance with ADLs and ambulated 100 ft with assistive device. He experienced a severe gout flare and could no longer bear weight. Definitive treatment with pegloticase was deferred due to cost and level of clinical monitoring needed. However, with significant advocacy from our physiatry team due to severe pain and limited functional recovery, he received the first dose on our unit, which was previously unprecedented. After starting pegloticase, he improved to a supervision level with mobility, transfers, and ADLs prior to discharge to a skilled nursing facility.

Conclusion: As physiatrists, patient advocacy is crucial in the management of complex patient diagnoses and systems such as interdisciplinary teams, hospitals, and insurance companies.