How to manage a patient with gout, osteoarthritis, and mental health disorders presenting with ankle pain, knee instability, and dizziness?

Management of Gout, Osteoarthritis, and Hypotension in a Patient with Mental Health Disorders

For this patient with gout flare, osteoarthritis, and hypotension, treatment should focus on oral corticosteroids for the acute gout attack, along with lifestyle modifications, while addressing the hypotension as a priority to improve dizziness symptoms. 1

Acute Gout Management

• Oral corticosteroids (prednisolone 30-35mg daily for 3-5 days) are strongly recommended as first-line therapy for this patient's gout flare, given the patient's allergy to ibuprofen and low blood pressure 1
• Low-dose colchicine is not recommended in this case due to the patient's hypotension (BP 92/68) and potential interactions with the patient's multiple medications 2
• Topical ice should be used as an adjuvant treatment to help reduce pain and inflammation in the affected ankle 1
• The patient should continue allopurinol during the acute attack to maintain urate-lowering therapy 1, 3

Osteoarthritis Management

• Physical therapy referral is recommended for the knee instability and clicking, focusing on strengthening exercises to improve joint stability 1
• Consider orthotic support (ankle brace, supportive shoes) to reduce pain with walking and standing 1
• Weight management should be discussed as part of the treatment plan, as this can reduce symptoms in both gout and osteoarthritis 1
• Acetaminophen (paracetamol) can be continued for osteoarthritis pain management, as the patient is already taking it PRN 1

Hypotension Management

• The patient's low blood pressure (92/68) requires immediate attention as it likely contributes to the reported dizziness and fatigue 3
• Review and consider adjusting medications that may contribute to hypotension, particularly:
  • Spironolactone 100mg dose should be reduced or temporarily discontinued 3
  • Consider timing of antipsychotic medications (risperidone) to minimize orthostatic effects 3
• Recommend increased fluid intake, adequate salt intake, and compression stockings to improve blood pressure 3
• Advise the patient to rise slowly from sitting or lying positions to minimize orthostatic symptoms 3

Lifestyle Modifications

• Limit alcohol intake, especially beer and spirits, which can trigger gout flares 1
• Reduce intake of high-fructose corn syrup and purine-rich foods (organ meats, shellfish) 1, 4
• Encourage consumption of low-fat dairy products which may be protective against gout 1, 4
• Implement a gradual exercise program once acute pain subsides, focusing on non-weight-bearing activities initially 1

Medication Adjustments

• Maintain allopurinol at current dose (300mg twice daily) as it's appropriate for long-term urate-lowering therapy 1
• Consider adding prophylactic low-dose corticosteroids temporarily to prevent gout flares while continuing urate-lowering therapy 1, 3
• Monitor renal function regularly due to multiple medications and history of gout 2
• Ensure the patient receives nicotine gum as prescribed to prevent withdrawal symptoms that could exacerbate mental health conditions 3

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks to assess response to treatment and blood pressure status 3
• Monitor serum urate levels with target of <6 mg/dL (360 μmol/L) 1, 3
• Assess ankle swelling and pain regularly to determine effectiveness of treatment 1
• Evaluate for need for knee imaging if clicking and instability persist despite conservative measures 1

Common Pitfalls to Avoid

• Avoid NSAIDs completely due to the patient's allergy to ibuprofen 1
• Do not discontinue allopurinol during acute gout flares as this may prolong the attack 1, 3
• Avoid standard doses of colchicine given the patient's hypotension and multiple medications that may interact 2
• Do not ignore hypotension as it significantly impacts quality of life through dizziness and fatigue symptoms 3
• Avoid rapid dose escalation of urate-lowering therapy which could trigger more gout flares 1