What is the recommended treatment for an elderly woman with severe pain, redness, and swelling of her great toe, elevated uric acid levels, leukocytosis, and mild anemia, with a history of similar episodes?

Treatment of Recurrent Acute Gout in an Elderly Patient

This elderly woman with recurrent gout (four episodes in one year) requires immediate treatment of the acute flare with corticosteroids, NSAIDs, or low-dose colchicine, followed by initiation of long-term urate-lowering therapy with allopurinol given her recurrent attacks. 1

Immediate Management of the Acute Flare

First-Line Anti-Inflammatory Options

• Corticosteroids are strongly recommended as first-line therapy in this elderly patient given the high likelihood of renal impairment and contraindications to NSAIDs in this age group 1

  • Oral prednisone 30-40 mg daily for 5-7 days, or
  • Intra-articular corticosteroid injection if only the great toe is involved (highly effective and safe) 1

• NSAIDs can be used if no contraindications exist (renal impairment, cardiovascular disease, gastrointestinal bleeding risk), but are often problematic in elderly patients 1

• Low-dose colchicine (0.5-0.6 mg three times daily, maximum 1.2 mg/day) is an alternative, though dose reduction is critical in elderly patients with potential renal impairment 1

  • High-dose colchicine should be avoided due to increased toxicity risk 1

Critical Caveat for Elderly Patients

• NSAIDs are not recommended in patients with chronic kidney disease as they can cause acute kidney injury, which is particularly concerning given this patient's mild anemia suggesting possible renal involvement 2
• Colchicine toxicity increases significantly with renal impairment and requires dosage reduction 2

Long-Term Urate-Lowering Therapy (ULT)

Strong Indication for ULT Initiation

This patient has a clear indication to start urate-lowering therapy immediately based on recurrent attacks (four episodes in one year) 1

• The American College of Physicians strongly recommends against initiating ULT after a first attack, but strongly recommends discussing ULT initiation in patients with recurrent gout attacks 1
• Recurrent attacks are defined as more than one attack per year 1

First-Line ULT: Allopurinol

Allopurinol is strongly recommended as the preferred first-line urate-lowering agent, even in patients with moderate-to-severe chronic kidney disease 1

Allopurinol Dosing Strategy

• Start at 100 mg daily (or 50 mg daily if significant renal impairment) 1, 3
• Increase by 100 mg increments every 2-4 weeks until serum uric acid target is achieved 1
• Maximum FDA-approved dose is 800 mg/day 1
• Target serum uric acid level: <6 mg/dL (360 μmol/L) 1

Critical Safety Monitoring

• Patients must be warned to discontinue allopurinol immediately at the first sign of skin rash and contact their physician, as this may herald allopurinol hypersensitivity syndrome 3
• Starting at low doses significantly reduces the risk of hypersensitivity reactions 1

Mandatory Flare Prophylaxis During ULT Initiation

Prophylactic colchicine (up to 1.2 mg daily) or low-dose corticosteroids must be given when starting urate-lowering therapy to prevent acute flares during the initial 6 months 1, 3

• The mobilization of urate from tissue deposits causes fluctuations in serum uric acid that trigger acute attacks 3
• Prophylaxis should continue for at least 6 months 1
• If colchicine is contraindicated or not tolerated, low-dose NSAIDs or corticosteroids may be used 1

Essential Non-Pharmacologic Management

Every gout patient must receive comprehensive lifestyle counseling 1, 4:

• Weight loss if obese 1, 4
• Limit alcohol intake, especially beer and spirits 1, 4
• Avoid sugar-sweetened drinks and excessive fructose 4
• Reduce intake of meat and seafood 4
• Encourage low-fat dairy products (protective effect) 4
• Maintain fluid intake of at least 2 liters daily 3

Monitoring Strategy

• Serum uric acid should be monitored regularly and maintained below 6 mg/dL 1
• Monitor renal function closely during early allopurinol therapy, especially in elderly patients 3
• Assess frequency of gout attacks to evaluate treatment efficacy 1

Common Pitfall to Avoid

Do not delay ULT initiation in this patient with recurrent attacks. The presence of four episodes in one year represents recurrent gout requiring long-term urate-lowering therapy, not just symptomatic treatment of acute flares 1. The subcortical cysts on x-ray indicate chronic disease with ongoing urate deposition 1.