What is the appropriate management for a patient with shortness of breath, chest pain, and a gout flare, with a history of hypertension, hyperlipidemia, and chronic smoking?

Management of Shortness of Breath, Chest Pain, and Gout Flare in a Patient with Multiple Comorbidities

This patient requires immediate treatment for acute gout flare with NSAIDs or colchicine, antibiotics for likely respiratory infection, initiation of inhaler therapy for suspected COPD, and restart of allopurinol for long-term gout management, along with addressing lifestyle modifications for smoking and alcohol consumption. 1

Acute Management

Respiratory Symptoms Management

• Initiate inhaler therapy with Seretide (combination corticosteroid/long-acting beta-agonist) and Ventolin (short-acting beta-agonist) for suspected COPD with acute exacerbation 1
• Prescribe antibiotics for likely respiratory infection, as the patient presents with productive cough, fine crackles on examination, and appears unwell 2
• Monitor oxygen saturation (currently 98%) and vital signs, with particular attention to blood pressure (currently elevated at 152/108) 1
• Obtain blood tests including troponin to rule out cardiac causes of chest pain, despite ECG showing no acute changes 1

Acute Gout Management

• For the acute gout flare in the left knee, initiate one of the following first-line options:
  • Colchicine (if within 12 hours of flare onset): loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 1
  • NSAID (with proton pump inhibitor if appropriate) 1
  • Oral corticosteroid (30-35 mg/day of equivalent prednisolone for 3-5 days) 1
• Consider joint aspiration and injection of corticosteroids if pain is severe and not responding to oral therapy 1

Long-term Management

Gout Management

• Restart allopurinol for long-term urate-lowering therapy (ULT), starting at 100 mg/day and increasing by 100 mg increments every 2-4 weeks until reaching target serum uric acid level <6 mg/dL (360 mmol/L) 1, 3
• Maximum dosage of allopurinol should be adjusted based on renal function if impaired 1
• Provide prophylaxis against flares during the first 6 months of ULT with colchicine 0.5-1 mg/day (dose reduced in renal impairment) 1
• Monitor serum uric acid levels regularly to maintain <6 mg/dL (360 mmol/L) 1

Hypertension Management

• Continue current antihypertensive medications: losartan and amlodipine 4, 5
• Consider adding additional antihypertensive if BP remains elevated despite current therapy 1
• Losartan is particularly beneficial in this patient as it has uricosuric properties that can help with gout management 1, 4

COPD/Respiratory Management

• Provide education on proper inhaler technique through nursing staff 1
• Schedule follow-up in 10 days to assess response to treatment and consider chest X-ray and pulmonary function testing to confirm COPD diagnosis 1
• Consider referral to pulmonologist if symptoms persist or diagnosis remains unclear 6

Lifestyle Modifications

• Smoking cessation counseling is essential as the patient has a significant smoking history (20 cigarettes/day since 1970) which is likely contributing to respiratory symptoms 1, 6
• Alcohol reduction advice is crucial as the patient consumes 24 bottles per weekend, which can exacerbate gout and contribute to other health issues 1
• Dietary modifications for gout management:
  • Avoid excessive intake of meat, seafood, beer, spirits, and sugar-sweetened drinks 1
  • Encourage consumption of low-fat dairy products 1
  • Recommend weight loss if appropriate 1
  • Encourage regular exercise as tolerated 1

Follow-up Plan

• Health coach appointment same day for lifestyle modification support 1
• Urgent attention if symptoms worsen or do not improve 1
• Follow-up in 10 days to:
  • Assess response to treatment
  • Consider chest X-ray
  • Consider pulmonary function testing for COPD diagnosis
  • Monitor blood pressure
  • Check compliance with medications
  • Review serum uric acid levels 1

Common Pitfalls and Caveats

• Avoid colchicine in patients with severe renal impairment or those receiving strong P-glycoprotein and/or CYP3A4 inhibitors 1
• Be cautious with NSAIDs in patients with renal impairment, history of gastrointestinal bleeding, or cardiovascular disease 1
• Monitor for potential drug interactions between allopurinol and other medications 3
• Recognize that poor adherence to allopurinol is common and contributes to recurrent gout flares; patient education is essential 1
• Consider that shortness of breath may have multiple contributing factors in this patient (COPD, infection, possible cardiac cause) and requires comprehensive evaluation 6
• Do not delay ULT initiation, as early treatment can prevent recurrent gout attacks and complications 1