Case 3: Acute Gout—Risk Factors and Inappropriate Therapy

Case

Patient MA, a 56-year-old postmenopausal white woman with sudden onset of acute pain in the right great toe, was seen by her primary care physician the following day. She walked with support from her husband because she was unable to walk or bear weight without assistance. The patient—a homemaker—reported that she had had 2 previous episodes of similar pain in the great toe and ankle lasting 4 to 5 days that were treated by emergency room physicians with analgesics.

History and physical examination

The patient’s past history was unremarkable except for a recent weight loss of approximately 25 lb (11.25 kg) over 3 months related to the initiation of the Atkins diet and the prescribing of a thiazide diuretic for mild hypertension. Physical examination revealed a blood pressure reading of 138/86 mm Hg, a weight of 185 lb (83.25 kg), body mass index (BMI) of 31.8, and height of 5′4″ (162.56 cm). Patient MA presented with an acutely swollen, red, and tender right great toe. She was diagnosed

Discussion

The case of Patient MA illustrates that urate-lowering therapy should not be initiated during an acute attack, because it will prolong the attack or “make the whole thing worse,” as Patient MA stated so succinctly. It is also important to wait 4 to 6 weeks after an acute gout attack before instituting urate-lowering therapy. (However, should an attack occur while the patient is taking allopurinol, treatment must continue.)

The case also underscores some of the lifestyle- and medication-related

Nonmodifiable risk factors for gout

Age is the primary nonmodifiable risk factor for gout. The increasing longevity of populations in the United States may contribute to an increased prevalence of gout through an association with age-related diseases and treatments for age-related diseases. Moreover, the clinical manifestations of gout are more likely to present in patients with long-standing hyperuricemia. In this case, Patient MA is 56 years old and, therefore, at substantially higher risk for gout than a younger patient.

Sex is

Modifiable risk factors for gout

Modifiable risk factors for gout include serum urate levels, diet, alcohol intake, use of certain medications, hypertension, renal disease, transplantation, obesity, and the metabolic syndrome.

Additional considerations

Patient MA should be advised to further reduce her weight and to limit her intake of alcoholic beverages. A low-purine, protein-restricted diet is advisable; however, most patients find such a diet unpalatable. Moreover, purine-restricted diets, when followed closely, result in only small (1 to 2 mg/dL [0.6 to 0.12 mmol/L]) decreases in serum urate levels.³ Because dietary control is impractical in many patients, many will benefit from treatment with a urate-lowering drug.

Teaching points

• •

  Urate-lowering therapy should not commence during an acute gout attack

  • —

    Wait 4 to 6 weeks

  • —

    Should an attack occur while on allopurinol, continue therapy

• •

  Colchicine and nonsteroidal anti-inflammatory drugs are not urate-lowering agents; reserve them for suppression of recurrent attacks

• •

  Risk factors for gout include:

  • —

    Serum urate levels >6.8 mg/dL (>0.41 mmol/L)

  • —

    Hypertension

  • —

    Medications (low-dose aspirin, diuretics, certain immunosuppressive agents)

  • —

    Obesity

  • —

    Metabolic syndrome

  • —

    Intake of high-purine foods and