What is the best treatment for an acute gout flare in a 64-year-old male (M) with chronic recurrent diverticulitis, experiencing 3 days of metatarsophalangeal (MTP) joint pain?

From the Guidelines

For acute gout flare in a 64-year-old male with chronic recurrent diverticulitis and 3 days of MTP pain, the recommended treatment is colchicine, starting with 1.2 mg orally followed by 0.6 mg one hour later, then continuing with 0.6 mg once or twice daily until the flare resolves, as recommended by the American College of Physicians 1. Given the patient's history of diverticulitis, NSAIDs should be avoided as they can exacerbate gastrointestinal inflammation.

• Oral corticosteroids are another option if colchicine is contraindicated or poorly tolerated;
• prednisone 30-40 mg daily for 3-5 days followed by a taper over 7-10 days can be effective, as corticosteroids have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects 1. Some key points to consider in the management of acute gout flare include:
• Ice application to the affected joint for 20 minutes several times daily and rest can provide additional symptomatic relief.
• Adequate hydration should be maintained, and alcohol should be avoided during the flare.
• Colchicine works by inhibiting neutrophil migration and phagocytosis, thereby reducing the inflammatory response to urate crystals in the joint.
• After the acute flare resolves, the patient should be evaluated for long-term urate-lowering therapy to prevent recurrent attacks, especially if this is not his first gout flare, as recommended by the American College of Physicians 1.

From the FDA Drug Label

Clinical studies with colchicine for prophylaxis and treatment of gout flares and for treatment of FMF did not include sufficient numbers of patients aged 65 years and older to determine whether they respond differently than younger patients In general, dose selection for an elderly patient with gout should be cautious, reflecting the greater frequency of decreased renal function, concomitant disease or other drug therapy [see Dosage and Administration (2.4) and Use in Specific Populations (8. 5)] .

The best treatment for acute gout flare in a 64-year-old male with chronic recurrent diverticulitis and 3 days of MTP pain is not explicitly stated in the provided drug labels. However, considering the patient's age and potential for decreased renal function, cautious dose selection is recommended when using colchicine.

• The patient's renal function should be assessed before initiating treatment.
• Dose adjustment may be necessary based on the patient's renal function.
• The patient should be monitored closely for adverse effects of colchicine.
• Alternative therapies may be considered if the patient has severe renal impairment or other comorbidities. 2 2

From the Research

Treatment Options for Acute Gout

• The treatment of acute gout involves the use of various medications, including colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids 3, 4, 5, 6, 7.
• Colchicine is effective in treating acute gout, with low-dose colchicine being associated with fewer adverse events compared to high-dose colchicine 3, 4, 7.
• NSAIDs are also effective in treating acute gout, but their use may be limited in patients with certain comorbidities, such as renal or gastrointestinal disease 4, 5, 7.
• Corticosteroids, including systemic and intraarticular glucocorticoids, are effective in treating acute gout and may be preferred in patients with contraindications to colchicine or NSAIDs 4, 5, 7.

Considerations for Patients with Comorbidities

• Patients with chronic recurrent diverticulitis may require careful consideration when selecting a treatment for acute gout, as certain medications, such as NSAIDs, may exacerbate diverticulitis 5.
• The use of colchicine may be limited in patients with severe renal or hepatic dysfunction, and alternative treatments, such as corticosteroids, may be preferred 5.
• The management of gout in patients with comorbidities requires careful selection of treatment based on potential benefits and consequences of therapy, considered in tandem with individual patient-specific characteristics 5.

Treatment Recommendations

• Low-dose colchicine may be a suitable treatment option for acute gout in patients with comorbidities, such as chronic recurrent diverticulitis, due to its efficacy and relatively favorable safety profile 3, 4, 7.
• Corticosteroids, including systemic and intraarticular glucocorticoids, may be preferred in patients with contraindications to colchicine or NSAIDs, or in patients with severe acute gout 4, 5, 7.
• The selection of treatment for acute gout should be individualized based on patient-specific factors, including comorbidities, medication tolerability, and treatment response 5, 6, 7.