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Mr J.P., a 43-year-old chemical engineer, is a relatively new patient in your practice. He is concerned about increasingly frequent episodes of “gout” over the past 6 months. He describes acute onset of red, swollen, painful joints in his big toes, ankles, and rarely his knees. He reports that he was diagnosed with gout 3 years ago, but cannot recall specific laboratory tests; he takes 50 mg of indomethacin 3 times daily, which is effective for each acute episode. He is now wondering about dietary and medical management to prevent gout, as the acute arthritis is interfering with his work (which involves frequent overseas travel) and his exercise (long-distance running). Mr J.P. has no other medical history of note; takes no other medications or supplements; and is a nonsmoker and has an alcohol intake of 1 to 2 glasses of wine per week. Results of his physical examination are unremarkable, with a body mass index of 25.9 kg/m2, blood pressure of 126/80 mm Hg, no acute arthritis, and no tophi. You provide Mr J.P. with a handout on a low-purine diet for gout and a requisition for laboratory tests.
The recurrent attacks over the past 6 months suggest this patient might have progressed to intercritical gout (ie, symptomatic gout with increasingly frequent attacks of acute gouty arthritis).28–35 Checking SUA levels would assist in deciding whether to begin preventive treatment.31,32 If SUA levels are elevated, the patient could either overproduce or underexcrete uric acid; SUA-lowering therapy with allopurinol might be beneficial in either situation.31,32
Mr J.P. returns 3 weeks later. His SUA level is elevated at 614 μmol/L (normal 150 to 480 μmol/L), despite his following a low-purine diet. Other test results were normal—serum creatinine was 74 μmol/L; fasting glucose was 5.4 mmol/L. Given that weight loss is not likely to provide the same benefits for this patient as would be seen in an obese individual, the final-year medical student working with you today suggests starting treatment with allopurinol. He is uncertain how to do this, as he recalls that the drug might precipitate an acute attack of gout.
Mr J.P. was started on 100 mg of allopurinol and 0.6 mg of colchicine daily. He had no acute attacks and no medication side effects. After 4 weeks of therapy his SUA level was 443 μmol/L, so the dose of allopurinol was titrated to ideally achieve an SUA level below 360 μmol/L. After 6 months of taking 300 mg of allopurinol daily, the patient had no further episodes of arthritis and was back running in half marathons; his SUA was 335 μmol/L. Colchicine prophylaxis had been stopped after 3 months.
Mr V.S., aged 76, is in your clinic complaining of 2 days of a red, swollen, and very painful right wrist and third proximal interphalangeal joint. He denies any trauma and states that this is similar to previous gout attacks. He was diagnosed with gouty arthritis about 10 years ago and has not had an attack for 3 years. He went to a medical clinic yesterday and was prescribed colchicine, 0.6 mg 3 times daily. Today he has severe nausea, mild diarrhea, and his hand does not feel much better. Examination confirms severe acute inflammatory arthritis.
Mr V.S. has long-standing hypertension, chronic atrial fibrillation, chronic kidney disease (estimated glomerular filtration rate of 35 mL/min), and obesity (body mass index of 32 kg/m2). Current medications include amlodipine 10 mg daily, perindopril 4 mg daily, hydrochlorothiazide 25 mg daily (dose increased from 12.5 mg daily about 6 months ago), metoprolol 25 mg twice daily, and warfarin 5 mg daily. He is an ex-smoker and abstains from alcohol. What are your therapeutic options for this acute episode of gouty arthritis?
In a patient like Mr V.S., who has a history of hypertension and chronic kidney disease, NSAIDs are best avoided.44 Furthermore, he has had an adverse reaction to low-dose colchicine (gastrointestinal upset), which also did not provide adequate pain relief. Because the attack appears to be polyarticular, a short course of oral prednisone is reasonable41 (See Table 110–16 for dosage suggestions). It is possible that the recent attacks are drug-induced; therefore, consider stopping the hydrochlorothiazide and restarting the patient at 12.5 mg daily after the attack has resolved.
Mr V.S. returns to you 8 months later, having had 3 more episodes of acute arthritis involving his foot and hand, including 2 attacks after he self-terminated his hydrochlorothiazide therapy. He wants preventive therapy. His SUA level is 418 μmol/L, and his renal function remains stable.
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* The full version of the RxFiles gout treatment chart and gout newsletter are available at www.cfp.ca. Go to the full text of the article on-line, then click on CFPlus in the menu at the top right of the page.