From the Guidelines
For an acute gout flare in a patient with normal renal function, diabetes on metformin, and taking apixaban, the best treatment is a short course of oral colchicine or oral prednisone. The patient's normal renal function and absence of allopurinol treatment suggest that colchicine can be used at a dose of 1.2 mg initially, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily for 7-10 days 1. However, considering the patient is on apixaban, which increases bleeding risk with NSAIDs, colchicine or oral prednisone at 30-40 mg daily for 3-5 days, followed by a taper over 7-10 days, would be a safer option 1. Ice application to the affected joint and rest are important adjunctive measures. The patient should avoid alcohol and purine-rich foods during the flare. These treatments work by reducing inflammation in the affected joint where urate crystals have triggered an intense inflammatory response. Some key points to consider in the management of gout include:
- The importance of treating acute flares early and effectively to reduce pain and inflammation
- The need to consider the patient's renal function and other medications when choosing a treatment for acute gout
- The role of lifestyle modifications, such as avoiding alcohol and purine-rich foods, in managing gout
- The potential benefits and risks of different treatments, including colchicine, NSAIDs, and corticosteroids Once the acute flare resolves, the patient should be evaluated for chronic gout management, which may include starting allopurinol to prevent future attacks by lowering serum uric acid levels 1.
From the FDA Drug Label
For treatment of gout flares in patients with mild (Clcr 50 to 80 mL/min) to moderate (Clcr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine
The patient has a normal renal function with a GFR of 80. The best way to manage an acute gout flare in this patient is to use colchicine with close monitoring for adverse effects. Dose adjustment is not required for this patient with mild renal impairment. However, it's essential to consider potential drug interactions with Eliquis (Apixaban) and Metformin, although the label does not provide direct information on these interactions. Given the patient's diabetes and anticoagulant therapy, careful monitoring and caution are advised when using colchicine 2.
From the Research
Treatment Options for Acute Gout Flare
- Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, and they are equally efficacious 3.
- Colchicine is an effective treatment for acute gout flares, and its recommended dosage is 1.2 mg at the first sign of the flare, followed by 0.6 mg in 1 hour 4.
- The choice of treatment for acute gout should be guided by comorbidities, such as diabetes and renal function 3.
Considerations for Patients with Diabetes and Normal Renal Function
- For patients with normal renal function, such as a GFR of 80, the treatment options for acute gout flare are not limited by renal function 5, 3.
- Metformin, a medication for diabetes, does not have a significant interaction with colchicine or other treatments for acute gout flare 4, 3.
- Eliquis (Apixaban), an anticoagulant, does not have a significant interaction with colchicine or other treatments for acute gout flare, but caution should be exercised when using multiple medications 4, 3.
Urate-Lowering Therapy (ULT)
- ULT, such as allopurinol, should be initiated in the majority of cases already after the first attack of gout, but it is not necessary to start ULT during an acute flare 6.
- For patients not on allopurinol, ULT can be initiated after the acute flare has resolved, and the treatment target should be a blood urate of < 360 µmol/l or < 300 µmol/l (in the presence of tophi) 6.