What is the appropriate management for a suspected gout flare in a 65-year-old man with left ankle pain?

Management of Suspected Gout Flare in a 65-Year-Old Man

For a 65-year-old man with left ankle pain suspected to be a gout flare, oral colchicine, NSAIDs, or glucocorticoids should be used as first-line therapy, with the specific choice based on the patient's comorbidities and medication history. 1

Diagnostic Approach

When evaluating suspected gout in this patient, consider:

• Clinical presentation: Acute onset of severe pain, erythema, and swelling in the ankle joint
• Risk factors: Age, gender, previous episodes, diet high in purines, alcohol consumption
• Joint aspiration: If diagnosis is uncertain, joint aspiration with polarized microscopy to identify monosodium urate crystals is the gold standard for diagnosis

First-Line Treatment Options

The 2020 American College of Rheumatology guidelines strongly recommend three equally effective first-line options for acute gout flare management:

1. Colchicine:

   • Low-dose regimen: 1.2 mg immediately followed by 0.6 mg one hour later
   • Must be started within 36 hours of symptom onset for maximum effectiveness
   • Strongly preferred over high-dose colchicine due to better safety profile 1, 2

2. NSAIDs (e.g., naproxen 500mg twice daily for 5 days)

   • Avoid in patients with renal impairment, peptic ulcer disease, or uncontrolled hypertension

3. Glucocorticoids:

   • Oral: Prednisone 30-35mg daily for 3-5 days
   • Intra-articular: Option for single joint involvement
   • Parenteral (IM/IV): Preferred when oral dosing not possible 1

Treatment Selection Considerations

Choose therapy based on:

• Comorbidities (renal function, cardiovascular disease, diabetes)
• Medication interactions
• Previous response to therapy
• Timing since symptom onset

Special Considerations for Elderly Patients

For this 65-year-old patient:

• Use caution with NSAIDs due to increased risk of GI bleeding and renal impairment
• Consider lower starting doses of colchicine if renal function is impaired 3
• Glucocorticoids may be preferred if NSAIDs are contraindicated, but monitor for effects on blood glucose if diabetic 2

Adjunctive Measures

• Topical ice application is conditionally recommended as an adjuvant treatment 1
• Rest and elevation of the affected joint
• Adequate hydration

Follow-up and Long-term Management

If this is a recurrent episode (≥2 attacks per year) or if tophi are present, consider:

1. Urate-lowering therapy (ULT):

   • Allopurinol is the strongly recommended first-line agent 1
   • Start at low dose (100 mg daily or lower in renal impairment) with gradual titration
   • Target serum urate level <6 mg/dL

2. Prophylaxis when starting ULT:

   • Strongly recommended to prevent flares during ULT initiation
   • Continue for 3-6 months after reaching target urate level 1
   • Options include low-dose colchicine, NSAIDs, or low-dose prednisone

3. Lifestyle modifications:

   • Limit alcohol intake (especially beer)
   • Limit purine-rich foods (organ meats, shellfish)
   • Limit high-fructose corn syrup intake
   • Weight loss program if overweight/obese 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset
• Using high-dose colchicine regimens
• Discontinuing ULT during acute flares
• Failing to provide prophylaxis when initiating ULT
• Inadequate dose titration of allopurinol to reach target serum urate levels 2
• Overlooking drug interactions, particularly with colchicine and P-glycoprotein/CYP3A4 inhibitors 3

By following these evidence-based recommendations, the patient's acute gout flare can be effectively managed while minimizing the risk of future attacks.