What are the next best steps in managing a patient with a history of gout, currently on allopurinol (300mg daily), who has experienced two recent flares despite treatment with naproxen (500mg three times a day) and a Medrol (methylprednisolone) dose pack, with worsening symptoms after initial improvement?

From the Guidelines

For a patient with gout experiencing recurrent flares despite allopurinol 300mg daily, the next best steps include initiating colchicine 0.6mg twice daily for acute flare management, increasing allopurinol to 400mg daily, and adding a prophylactic anti-inflammatory regimen of colchicine 0.6mg daily for 3-6 months, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Key Considerations

• The patient should discontinue naproxen and the medrol dose pack as these provide only temporary relief.
• Uric acid levels should be checked to ensure the target of <6 mg/dL is being achieved, as suggested by the guideline 1.
• If the patient cannot tolerate increased allopurinol, febuxostat 40-80mg daily could be considered as an alternative, based on the evidence from the American College of Physicians guideline 1.

Adjunctive Measures

• Adequate hydration (2-3 liters of water daily) is important to help prevent crystal formation.
• Dietary modifications, such as reducing purine-rich foods, alcohol, and high-fructose corn syrup, are also crucial in managing gout.

Goal of Treatment

• The goal is to prevent crystal formation by maintaining uric acid below saturation levels, which requires both pharmacological intervention and lifestyle modifications, as emphasized by the guidelines 1.

Prognosis and Monitoring

• Regular monitoring of uric acid levels and gout symptoms is necessary to adjust treatment and prevent future flares.
• The patient should be educated on the importance of adherence to treatment and lifestyle modifications to achieve optimal outcomes.

From the FDA Drug Label

The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases The attacks usually become shorter and less severe after several months of therapy. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage. While adjusting the dosage of allopurinol tablets in patients who are being treated with colchicine and/or anti-inflammatory agents, it is wise to continue the latter therapy until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months

The next best steps in management for this patient are:

• Continue allopurinol 300mg daily as the patient is already on this dose and it is within the recommended range for gout management 2
• Add colchicine as a prophylactic measure to prevent further gout attacks, as the patient has had two flares in the last month 2
• Consider adjusting the dose of allopurinol if the patient's serum uric acid level is not within the target range, but this should be done cautiously and with monitoring of serum uric acid levels 2
• Continue to manage acute gout attacks with anti-inflammatory agents such as naproxen or medrol dose pack as needed, until the patient has been free from acute attacks for several months 2

From the Research

Management of Gout Flares

• The patient is currently experiencing a gout flare, despite being on allopurinol 300mg daily, and has had two flares in the last month, treated with naproxen and medrol dose pack 3.
• Therapeutic options for treating acute gout flares include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids 3, 4, 5.
• The patient's current symptoms have worsened, indicating the need for re-evaluation of treatment.

Urate-Lowering Therapy

• Allopurinol is an agent of first choice for urate-lowering therapy, and the patient is already on a daily dose of 300mg 6, 4.
• The median daily dose of allopurinol at both the start and end of treatment was 300mg, and the dose was rarely increased during follow-up 6.
• Febuxostat is another efficacious urate-lowering therapy, but it has received a U.S. FDA black box warning for cardiovascular safety 4.

Next Steps in Management

• Consider adding colchicine as a flare prevention medication, as it has been shown to be effective in preventing gout flares 3, 4, 5.
• Evaluate the patient's serum urate level and consider adjusting the urate-lowering therapy to achieve a target level of less than 6mg/dl, or less than 5mg/dl for patients with more severe disease 5.
• Consider the use of anti-inflammatory prophylaxis, such as NSAIDs or corticosteroids, to manage the patient's current flare 3, 4, 5.