Individualizing the treatment of gout
GARY S. HOFFMAN, MD
TERESA M. GEORGE, MD
BRIAN F. MANDELL, MD, PhDAddress reprint requests to B.F.M., Department of Rheumatic and Immunologic Disease, A50, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
Treatment for gouty arthritis should be individualized to address the patient’s other medical problems and the likelihood that gout will become chronic. We present a typical case and review the options, explaining their utility for this and other patients.KEY POINTS
There are four options in treating an acute attack of gout: nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroids, and analgesia with observation. NSAIDs should be used cautiously (if at all) in elderly patients and patients with a history of peptic ulcer disease or renal insufficiency. Colchicine may abort an attack, but has potential side effects that limit its use. Corticosteroids, either injected into the joint or given by mouth, intramuscularly, or intravenously, provide an option to patients who cannot tolerate NSAIDs or colchicine. Colchicine at low daily doses may help prevent recurrent attacks. If a uric acid-lowering drug is started during an acute attack, the resulting decrease in serum uric acid concentration may exacerbate the attack. Therefore, these agents should be started no sooner than 2 to 3 weeks after an acute attack has resolved, and patients should be taking anti-inflammatory therapy several days before beginning hypouricemic therapy. The goal of uric acid-lowering therapy is a serum level less than 6 mg/dL.