What is the next step in management for a 70-year-old male with a mildly elevated erythrocyte sedimentation rate (ESR) and hyperuricemia, with a history of multiple gout flares?

From the Guidelines

The next step in management for this 70-year-old male with mildly elevated ESR and hyperuricemia with multiple gout flares would be to initiate urate-lowering therapy (ULT), specifically allopurinol starting at 100 mg daily, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The dose should be gradually titrated upward every 2-4 weeks based on serum uric acid levels, with a target of less than 6 mg/dL. Before starting allopurinol, HLA-B*5801 testing should be considered, especially if the patient is of Korean, Han Chinese, or Thai descent due to increased risk of severe cutaneous adverse reactions. Prophylaxis with colchicine 0.6 mg once or twice daily should be provided for the first 3-6 months of ULT to prevent gout flares that commonly occur when initiating treatment, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Renal function should be assessed before starting therapy, as allopurinol dosing may need adjustment in patients with kidney impairment. The mildly elevated ESR should be monitored but may be related to the inflammatory nature of gout. Long-term ULT is necessary as it addresses the underlying cause of gout by reducing serum urate levels, which prevents crystal formation in joints and tissues, ultimately reducing the frequency of painful flares and preventing joint damage. Regular monitoring of uric acid levels every 2-4 weeks during dose titration and then every 6 months once at target is essential for effective management. Key considerations in managing gout include:

• Initiating ULT for patients with frequent gout flares, tophaceous gout, or radiographic damage due to gout
• Using allopurinol as the preferred first-line ULT
• Implementing a treat-to-target management strategy with ULT dose titration guided by serial serum urate measurements
• Providing concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months when initiating ULT.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage.

The next step in management for a 70-year-old male with a mildly elevated erythrocyte sedimentation rate (ESR) and hyperuricemia, with a history of multiple gout flares, is to:

• Initiate allopurinol therapy with a low dose of 100 mg daily
• Gradually increase the dose at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
• Monitor serum uric acid levels and adjust the dosage as needed to maintain a normal or near-normal level
• Consider prophylactic colchicine to prevent acute gouty attacks during the early stages of allopurinol therapy 2
• Maintain adequate hydration with a daily urinary output of at least 2 liters and a neutral or slightly alkaline urine pH 2

From the Research

Management of Gout

The next step in management for a 70-year-old male with a mildly elevated erythrocyte sedimentation rate (ESR) and hyperuricemia, with a history of multiple gout flares, involves several considerations:

• Urate-lowering therapy is a key component in the management of gout, particularly in patients with a history of multiple flares and hyperuricemia 3, 4, 5, 6.
• The goal of urate-lowering therapy is to reduce serum uric acid (sUA) levels to less than 6 mg/dL, and even lower in patients with severe gout 3.
• Available urate-lowering medications include xanthine-oxidase inhibitors such as allopurinol and febuxostat, as well as uricosuric agents like benzbromarone and probenecid 3, 4, 5.
• Febuxostat has been shown to be effective in lowering sUA levels and reducing the frequency of gout flares, and may be considered as a first-line treatment option 3, 6.
• Allopurinol is also an effective urate-lowering therapy, and has been shown to be noninferior to febuxostat in controlling gout flares 6.

Considerations for Elevated ESR

• A mildly elevated ESR may indicate ongoing inflammation, and further evaluation may be necessary to determine the underlying cause 7.
• In patients with a history of gout, an elevated ESR may indicate a flare or ongoing disease activity.
• However, an elevated ESR can also be seen in other conditions, such as infections or malignancies, and further evaluation may be necessary to rule out these possibilities 7.

Treatment Options

• Urate-lowering therapy with febuxostat or allopurinol may be considered as a first-line treatment option for this patient.
• Anti-inflammatory prophylaxis may also be considered to reduce the risk of gout flares during the initial treatment period.
• Further evaluation and monitoring may be necessary to determine the underlying cause of the elevated ESR and to adjust treatment accordingly.