An 87-year-old woman was seen at the rheumatology because of chronic tophaceous gout. Monthly polyarticular gout flares afflicted both first metatarsophalangeal joints, as well as both wrists and multiple finger joints for approximately 4 years. The patient became bed-ridden, could not perform simple, everyday tasks of self-care (e.g., washing, dressing) and daily living (e.g., laundry, cooking), and required help from her daughter.
Two years earlier, her general practitioner had appropriately started allopurinol. However, after 4 weeks, the patient had developed an itching generalised exanthema, so that allopurinol had to be stopped. Benzbromarone was given at a dose of 50
mg q.d. but had an insufficient effect on serum uric acid levels, which still remained at 500μ
mol/L. During the last year, the patient had additionally developed multiple tophi located over the distal finger joints and both metatarsophangeal joints. Her pre-existing renal insufficiency had worsened (eGFR 30
mL/min). Further comorbidities of the patient included arterial hypertension, noninsulin-dependent diabetes mellitus, and permanent atrial fibrillation.
On the first admission to our department the patient was sitting in a wheelchair, appeared depressive, and suffered from severe pain (Visual analogue scale, VAS 8-9) and loss of function of distal finger joints, wrists and feet. Physical examination showed normal temperature, elevated blood pressure 160/80
Hg and an irregular pulse of 80–90 beats per minute. Otherwise, heart and lungs were normal, as were abdomen and the lumbar region. Joint examination revealed swollen painful wrists and distal finger joints with deformities and loss of mobility. Multiple subcutaneous tophi were visible (). Radiographs of both hands and feet showed tophaceous gout and destruction of multiple finger joints (). RBC, platelets, LFTs, LDH, protein-electrophoresis, and TSH were unremarkable. Leukocytosis (12.6
GPt/L), elevated CRP (25
mg/L), and serum urate (717μ
mol/L) were consistent with chronic gout. Her serum-creatinine (218μ
mol/L) and urea (25.2
mmol/L) were increased approximately threefold. The estimated glomerular filtration rate (eGFR) was calculated at 30
mL/min per 1.73
Clinical presentation: Tophi over the right distal interphalangeal joint II. (a) Before therapy with febuxostat. (b) After 10 months of therapy.
Radiograph of right hand showing the destructive character of recurrent crystal induced arthritis.
In this elderly lady with chronic tophaceous gout, significant renal impairment, and other comorbidities, we started urate lowering therapy with 80
mg of febuxostat q.d. (lower doses are not available in Germany). Concomitantly, prophylactic medication for expected gout attacks was started with 10
mg of Prednisolon q.d., 0.5
mg of colchicine e.o.d. day, and low-dose ibuprofen as needed. The patient was advised to carefully monitor daily fluid intake and urinary excretion. As early as one week after the first administration of febuxostat, serum urate level was reduced to 328μ
mol/L. Not surprisingly, given this steep decline in serum urate, the patient experienced another severe polyarticular gout flare. Tophi were visibly inflamed, and her eGFR decreased to 20
mL/min. Under forced diuresis and analgesia including narcotics, the situation stabilized within the next 4 weeks; the eGFR improved to 30
mL/min. After 5 months, the gouty attacks have stopped and the tophi have started to resolve (). Quality of life improved impressingly (pain on VAS 2-3), and the patient regained the ability to walk without help for up to half an hour.