What are the potential concerns for an 87-year-old patient treated for gout (gouty arthritis) in the foot/ankle area about a month ago, currently taking 40 milligrams of prednisone (Prednisone) daily for 5 days?

From the Guidelines

For an 87-year-old patient previously treated for gout in the foot/ankle with a 5-day course of prednisone 40mg daily one month ago, I recommend monitoring for complete resolution of symptoms and considering a preventive strategy. If the acute gout attack has resolved, no immediate additional treatment is needed. However, to prevent future attacks, the patient should be evaluated for long-term urate-lowering therapy such as allopurinol (starting at a low dose of 50-100mg daily) or febuxostat if allopurinol is not tolerated 1. The patient should maintain adequate hydration, limit alcohol consumption, and reduce intake of purine-rich foods like red meat and seafood. Regular monitoring of serum uric acid levels is important, aiming for levels below 6 mg/dL. Given the patient's advanced age, medication doses should be adjusted for kidney function, and drug interactions must be carefully considered 1. The short course of prednisone was appropriate for acute management, but long-term steroid use should be avoided due to significant side effects, especially in elderly patients 1. Gout occurs when uric acid crystals deposit in joints, causing inflammation, and proper management focuses on both treating acute attacks and preventing recurrences through uric acid control. Some key points to consider in the management of gout include:

• Patient education and lifestyle advice regarding weight loss, diet, and reduced alcohol consumption 1
• Addressing associated comorbidity and risk factors such as hyperlipidaemia, hypertension, and hyperglycaemia 1
• Using oral colchicine and/or NSAID as first-line agents for systemic treatment of acute attacks 1
• Considering urate-lowering therapy in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout 1
• Adjusting the dose of allopurinol according to renal function and monitoring for adverse effects 1

From the FDA Drug Label

Corticosteroids can produce reversible hypothalamic-pituitary adrenal (HPA) axis suppression with the potential for corticosteroid insufficiency after withdrawal of treatment. Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.

The patient is at risk for adrenocortical insufficiency after stopping 40 mg daily of prednisone for 5 days, due to HPA axis suppression.

• The patient should be monitored for signs of insufficiency.
• Gradual reduction of dosage is recommended to minimize the risk of insufficiency.
• If the patient experiences stress during the next 12 months, hormone therapy should be reinstituted 2.
• Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy 2.

From the Research

Gout Treatment and Management

• Gout is a common form of inflammatory arthritis with an increasing prevalence in developed countries 3.
• The treatment of gout flares and lowering serum urate are crucial aspects of gout management, with first-line agents including NSAIDs, colchicine, and glucocorticoids 4.
• For an 87-year-old patient treated for gout in the top of the foot/ankle, the use of 40 mg daily prednisone for 5 days may be a common approach for managing acute gout flares 4.

Urate-Lowering Therapy

• Allopurinol and febuxostat are commonly used urate-lowering therapies, with febuxostat having more comorbidities and greater health care utilization compared to allopurinol 3.
• A study comparing persistence rates between allopurinol and febuxostat as first-line urate-lowering therapy found that febuxostat had better persistence rates than allopurinol 5.
• The doses of allopurinol and febuxostat remained unchanged over time in most patients 3.

Treatment Guidelines and Recommendations

• Recent guidelines on the management of gout agree that anti-inflammatory treatment should start as soon as possible, preferably within 24 hours, and that treating to target of serum urate (sUA) less than 6 mg/dl is recommended 6.
• The use of low-dose colchicine and intra-articular, oral, or intramuscular steroids are also recommended for acute gout management 6.
• Allopurinol is generally preferred over febuxostat for urate-lowering therapy, although febuxostat may be a better option for long-term treatment in terms of medication adherence 5, 6.