What are the next steps in managing a 71-year-old male with a history of gout, presenting with gout and infection in one toe, who was recently treated in the emergency department (ED) with prednisone and Keflex (cephalexin) for gout and cellulitis in the other toe?

From the Guidelines

The next steps in managing a 71-year-old male with gout and infection in one toe, who recently received prednisone and cephalexin for gout and cellulitis in the other toe, should include treating the infection with a broad-spectrum antibiotic and managing the acute gout attack with colchicine or an NSAID, followed by initiation of urate-lowering therapy with allopurinol and prophylactic colchicine to prevent future flares, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Immediate Treatment

To address the infection, obtain cultures from the infected toe before starting antibiotics if possible. Prescribe a broad-spectrum antibiotic such as amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days. For the acute gout attack, continue or initiate colchicine 0.6 mg twice daily for 3 days, then once daily for 7-10 days, or use an NSAID like naproxen 500 mg twice daily if renal function is adequate, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

Long-term Management

Once the acute infection and gout flare resolve, initiate urate-lowering therapy with allopurinol, starting at 100 mg daily and gradually increasing to achieve a serum uric acid level below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Prophylactic colchicine 0.6 mg daily should be given during the first 3-6 months of allopurinol therapy to prevent flares. Regular monitoring of serum uric acid levels, renal function, and liver enzymes is essential.

Patient Education

Patient education about dietary modifications (limiting purine-rich foods, alcohol, and sugary beverages) and maintaining adequate hydration is important. This comprehensive approach addresses both the immediate infection and gout attack while establishing a plan to prevent future episodes through long-term urate-lowering therapy.

Key points to consider:

• The patient's recent treatment with prednisone and cephalexin for gout and cellulitis in the other toe should be taken into account when deciding on the next steps in management.
• The 2020 American College of Rheumatology guideline for the management of gout provides strong recommendations for the initiation of urate-lowering therapy and prophylactic colchicine to prevent future flares 1.
• Regular monitoring and patient education are crucial components of long-term management.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Managing Gout and Infection

The patient, a 71-year-old male with a history of gout, presents with gout and infection in one toe, having been recently treated in the ED with prednisone and Keflex for gout and cellulitis in the other toe. The next steps in managing this patient in the PCP office include:

• Assessing the current infection and gout flare, considering the recent treatment and potential for ongoing infection 2
• Evaluating the patient's renal function and serum uric acid concentration to guide the use of urate-lowering therapy, such as allopurinol, and adjusting the dose as needed 3, 4, 5
• Considering the patient's age and potential comorbidities, such as renal insufficiency, when selecting medications for gout management 5
• Providing patient education on gout management, including lifestyle modifications and medication adherence, to improve clinical outcomes 6
• Monitoring for potential interactions between medications, such as diuretics and urate-lowering therapy, and adjusting the treatment plan as needed 4, 5

Treatment Options

Treatment options for this patient may include:

• Continuing or adjusting the current antibiotic regimen to ensure adequate coverage of the infection 2
• Using anti-inflammatory agents, such as corticosteroids or NSAIDs, to manage the gout flare, while considering the patient's comorbidities and potential contraindications 3, 4, 6
• Initiating or adjusting urate-lowering therapy, such as allopurinol, to reduce serum uric acid levels and prevent future gout flares 3, 4, 5, 6
• Considering alternative treatments, such as colchicine or anti-IL-1β biological therapy, for gout flares that are not responsive to traditional therapies 4, 6

Important Considerations

Important considerations in managing this patient include:

• The potential for coincident bacterial infection and gout, and the need for diagnostic aspiration to rule out infection 2
• The importance of renal function and serum uric acid concentration in guiding the use of urate-lowering therapy 3, 4, 5
• The need for patient education and engagement in gout management to improve clinical outcomes 6
• The potential for interactions between medications and the need for careful monitoring and adjustment of the treatment plan 4, 5