E-case #10-B

Dena Kennedy, M.D.

August 20-24, 2001

69 year old Filipino male with past history of hyperuricemia and gout called pharmacy requesting a refill of colchicine and indomethocin, last filled several years ago, for acute podagra.  He has atopic disease with moderately severe asthma, hypertension (not on a diuretic), hx antral gastritis by EGD in '99, mild valvular heart disease, and hx "mildly abnormal kidney function tests" (at the VA where he is seen for hx of "service-connected" asthma disability. He had been advised to avoid NSAIDS and use Salsalate for joint symptoms.) His refill request was denied and an alternative treatment plan and visit/evaluation was recommended.

He loves to play tennis but had been troubled with a chronically painful bunion (for which he requested bunionectomy) and intermittent R knee pain which was intermittently painful, warm and felt "unstable."  He had no pain or knee instability when it wasn't acting up.  He recently sustained a knee strain when he slipped on the stairs while favoring his knee, which was painful at that time. He wanted to see the Orthopedist to have his knee "fixed" so he could continue competitive/recreational tennis.

1. What information would be gleaned from the visit that might change your treatment plans?

2. What laboratory information would you want to obtain?  How might that effect treatment options?

3. What are the best short and long-term treatment choices?

PE revealed a right MTP bunion without tophi but with warmth, erythema, tenderness and mild joint swelling.  No evidence for cellulitis.  He came wearing a very loose-fitting slipper. Walking was obviously painful. R knee was normal to exam, including ligamentous testing.

Lab notable for a creatinine of 1.5, serum uric acid of 9.1 and 24 hour urine creatinine clearance of 87 ml/min.  24 hour urine uric acid was 734 (250-750.)

This patient has an acute episode of podagra with perhaps intermittent sub-acute gout symptoms in first MTP and R knee. His past history and localization of symptoms made me comfortable treating him without a joint aspiration re: possible pseudogout or septic joint, including GC arthritis. Whereas pseudogout may effect the MCP joints (especially the first and second) as well as the knees, it rarely effect the MTP joints. Polyarticular gout occurs most often and with increasing frequency in patients with recurrent gout episodes and rarely as an initial episode of gout. The MTP joint is most frequently effected in gout as it is subject to repeated trauma, reduced temperatures and degenerative changes, factors which favor the precipitation of uric acid crystals.

He would benefit from acute gout treatment plus long-term gout treatment. If his chronic low-grade toe and knee symptoms improve, causes other than polyarticular gout become less likely. Resolution of chronic symptoms might obviate the need for podiatry or orthopedic evaluation or treatment.  Had tophi been present, the treatment of choice long term is allopurinol.  His medical history would argue against use of NSAIDS.  Salicylates effect the renal excretion of uric acid and should be avoided.  Diuretics for his hypertension should also be avoided.

Despite his elevated creatinine, his 24 hour creatinine clearance is normal. His 24 urine uric acid is in the upper normal range. Uric acid level is elevated, but patients may have acute gout episodes with normal or even low uric acid levels at the time of the acute attack. Uricosuric agents such as probenecid should be avoided in this patient.  The preferred treatment for his acute gout symptoms would be prednisone (about 40 mg/day) for 2 to 4 days. Colchicine can be used (0.6 mg q 1-2 hours until nausea/vomiting/diarrhea or gout symptoms resolve.  I try to avoid ever using this treatment method due to side effects.)  Renal complications of chronic hyperuricemia include (mostly radiolucent) kidney stones and urate nephropathy (medullary crystal deposition with minimally progressive azotemia and mild proteinuria).

After acute gout symptoms have resolved, the long-term goal would be to lower the uric acid into the normal range and follow symptoms. Good hydration is important. A low purine diet is recommended. (My patient had many foods on his list of favorites that were high in purines, in particular organ "meats", dried and pickled fish and gravy. Overall protein intake is high. He also likes a glass of wine or beer with dinner.) When beginning allopurinol, colchicine at 0.6 mg/day should initially be used concurrently to prevent precipitating an acute gout attack.  Periodically monitoring of uric acid levels is desired.

Reference

1. Boss, GR and  Seegmill, JE: Hyperuricemia and gout: classification, complications and management. NEJM 300:1459,1979.

2. Emmerson, BT: The management of gout. NEJM 334:445, 1996.

3. Fam, AG: Current therapy of acute microcrystalline arthritis and the role of corticosteroids. J Clin Rheumatology 3:35, 1997.

4. Agudelo, CA and Wise, CM: Crystal-associated arthritis. Clin Geriatr Med 14:495, 1998.

5. Pascual, E. The diagnosis of gout and CPPD crystal arthropathy. Br J Rheumatol 35:306, 1996.