What is the best management plan for a patient with ongoing gout pain, ankle pain, and toe pain, who also has diabetes, hypertension, and hyperuricaemia?

Management of Ongoing Gout with Multiple Comorbidities

This patient requires immediate optimization of urate-lowering therapy with dose-adjusted allopurinol, continuation of low-dose colchicine prophylaxis, careful management of the infected ankle wound, and aggressive treatment of cardiovascular risk factors including resumption of blood pressure control. 1

Immediate Priorities

1. Address the Infected Ankle Wound

• The localized red raised area with open center on the inner ankle, though completed on flucloxacillin, requires continued monitoring for cellulitis or abscess formation, particularly given diabetes with nephropathy 1
• Continue topical wound care and consider extending oral antibiotics if signs of spreading infection develop, as infection is a contraindication to certain gout treatments 1
• The wound soreness when walking may be contributing to overall ankle pain and must be distinguished from gouty inflammation

2. Optimize Gout Management During This Subacute Phase

Continue colchicine 0.5mg daily as prophylaxis - The patient is already on this medication, which is appropriate during ongoing gout symptoms and while optimizing urate-lowering therapy 1, 2

Assess and likely increase allopurinol dose - The patient is on allopurinol but the dose is not specified; given recurrent flares, the dose is likely insufficient 1, 2

• Start or increase allopurinol by 100mg increments every 2-4 weeks until serum uric acid <6 mg/dL (360 µmol/L) is achieved 1, 2
• Critical caveat: With diabetic nephropathy, dose adjustment is mandatory - if creatinine clearance is 10-20 mL/min, maximum dose is 200mg daily; if <10 mL/min, do not exceed 100mg daily 2
• Check serum creatinine and calculate creatinine clearance immediately to guide dosing 2

For current ankle/toe pain, add short-term anti-inflammatory therapy:

• Given the BP of 145/82 (now hypertensive after losartan discontinuation) and diabetes, oral prednisolone 30-35mg daily for 3-5 days is the safest option 1
• NSAIDs should be avoided given diabetic nephropathy and need to minimize cardiovascular risk 1
• Additional colchicine beyond prophylactic dosing is risky with renal impairment - low-dose colchicine (0.5mg three times daily) could be considered but watch for neurotoxicity/myotoxicity, especially with potential statin use 1

3. Manage Cardiovascular Risk Factors Aggressively

Blood pressure is inadequately controlled at 145/82 - The previous hypotension (96/63) that led to losartan discontinuation has resolved 1

• Resume losartan 50mg daily - This is particularly advantageous as losartan has uricosuric properties that help lower uric acid levels 3
• The combination of losartan for hypertension plus allopurinol for urate-lowering is ideal for this patient 3
• Continue amlodipine 5mg daily 1

Optimize diabetes control - Patient admits to missing metformin doses 1

• Reinforce adherence to metformin 500mg BD
• Check HbA1c to assess glycemic control
• Address diabetic nephropathy progression with regular monitoring of renal function 1

Address morbid obesity - Weight loss is a core management strategy with strong evidence 1

• A 5% reduction in BMI is associated with 40% lower odds of recurrent gout flares 4
• Provide specific dietary counseling: limit purine-rich foods (organ meats, shellfish), avoid beer and spirits, avoid sugar-sweetened beverages, encourage low-fat dairy products 1, 3

Monitoring Plan

Serum uric acid levels - Check now and every 2-4 weeks while titrating allopurinol until target <6 mg/dL achieved, then every 3-6 months 1, 2

Renal function - Check creatinine and calculate creatinine clearance now given diabetic nephropathy and need for dose-adjusted allopurinol 2

Blood pressure - Recheck in 1-2 weeks after resuming losartan to ensure no recurrent hypotension 1

Wound healing - Follow up in 1 week to ensure ankle wound continues to heal without signs of spreading infection 1

Patient Education

Explain the "treat to target" approach - The goal is to maintain serum uric acid <6 mg/dL indefinitely to dissolve existing crystals and prevent new crystal formation 1, 4

Warn about paradoxical flares - Starting or increasing allopurinol can initially trigger more gout attacks, which is why prophylactic colchicine must continue for at least 6 months 1, 2

Emphasize medication adherence - Missing doses of metformin, allopurinol, or colchicine undermines the entire treatment plan 1, 4

Self-management of future flares - Educate patient to start prednisolone at first warning symptoms of acute flare 1

Common Pitfalls to Avoid

• Do not stop allopurinol during an acute flare - Continue urate-lowering therapy and add anti-inflammatory treatment 1
• Do not use NSAIDs in this patient - Diabetic nephropathy is a contraindication 1
• Do not increase allopurinol rapidly - Gradual titration by 100mg every 2-4 weeks prevents flare precipitation 2
• Do not forget gastroprotection if NSAIDs were considered - Though avoided here, this would be essential 1
• Do not use high-dose colchicine - Low doses (0.5mg TID maximum) are equally effective with fewer side effects 1