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Question 4#

A 67-year-old man with a history of gout presents with intense pain in his right great toe. He has a complex past medical history, including hypertension, coronary artery disease, congestive heart failure, myelodysplasia, and chronic kidney disease with a baseline creatinine of 3.2 mg/dL and a uric acid level of 10 mg/dL. His medications include aspirin, simvastatin, clopidogrel, furosemide, amlodipine, and metoprolol.

What is the best therapy in this situation? 

A) Colchicine 1.2 mg po initially, followed by 0.6 mg 1 hour later
B) Allopurinol 100 mg po daily and titrate to uric acid less than 6 mg/dL
C) Prednisone 40 mg po daily
D) Naproxen 750 mg po once followed by 250 mg po tid
E) Probenecid 250 mg po bid

Correct Answer is C

Comment:

The first priority in treating acute gout is to control the inflammation. Nonsteroidal antiinflammatory agents or colchicine are usually used first line for acute gout; however, this patient has several contraindications to their use. Prednisone is very effective at treating acute gout in this situation and is the best choice given this patient’s comorbidities. Intra-articular injection of the affected joint with steroids is also effective but requires special expertise to perform the procedure. Colchicine is less well tolerated in the elderly and is contraindicated in patients with myelodysplasia. NSAIDs are contraindicated in this case due to the patient’s poor renal function as indicated by his creatinine of 3.2. Neither allopurinol nor probenecid are used in acute gout. Paradoxically, these agents, which lower serum uric acid levels in the long term, can cause worsening of acute gout. If the patient goes on to have numerous symptomatic episodes of gout or if tophaceous disease should develop, allopurinol can be started. Probenecid, a uricosuric agent, is ineffective in the setting of chronic kidney disease.