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Case
The patient is illustrative. Mr. W., 54, comes to the clinic with a hot, red, swollen left big toe that woke him in the night. This is his third flare in 10 months. He has hypertension treated with hydrochlorothiazide, stage 3a chronic kidney disease (eGFR 55 mL/min/1.73 m²) and a BMI of 33. He drinks 4 to 5 beers on weekends. His serum urate, checked 3 weeks after his last flare, was 9.1 mg/dL.
Question 1: How should this flare be treated?
The 2020 American College of Rheumatology gout guideline strongly recommends colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or glucocorticoids (oral, intra-articular or intramuscular) for gout flares (FitzGerald et al., 2020). With his kidney disease, an NSAID is a poor choice. Options are low-dose colchicine, with the dose adjusted for kidney function and drug interactions checked, or a short course of oral prednisone. Ice, rest and elevation help.
Question 2: Does he need urate-lowering therapy?
Yes. The guideline strongly recommends urate-lowering therapy for patients with frequent flares, tophi or radiographic damage from gout. Two or more flares a year count as frequent. Mr. W. has had three in 10 months.
Question 3: Which drug, and how should it be started?
| Guideline recommendation (FitzGerald et al., 2020) | Applied to Mr. W. |
|---|---|
| Allopurinol as the preferred first-line drug, including for moderate to severe chronic kidney disease | Start allopurinol |
| Low starting dose: 100 mg a day or less, and lower in chronic kidney disease | Start 50 mg daily because of his eGFR |
| Treat to target: adjust the dose using repeated serum urate measurements, aiming for below 6 mg/dL | Recheck urate every 2 to 5 weeks and increase the dose step by step |
| Anti-inflammatory prophylaxis for at least 3 to 6 months when starting | Low-dose colchicine daily, adjusted for kidney function |
| Testing for HLA-B*5801 before allopurinol in patients of Southeast Asian descent and African American patients (conditional) | Ask about ancestry and test if indicated, because this allele raises the risk of a severe allopurinol hypersensitivity reaction |
Teach Mr. W. that flares can increase in the first months of urate-lowering therapy, which is why prophylaxis matters, and that he shouldn't stop allopurinol during a flare.
Question 4: What else can be changed?
- Medications: hydrochlorothiazide raises urate. The guideline conditionally recommends switching to an alternative antihypertensive when feasible, and choosing losartan when possible, because it lowers urate. Coordinate with his blood pressure plan.
- Alcohol: conditionally recommended to limit it. Beer is particularly linked with flares.
- Weight: conditionally recommended weight loss for patients with overweight or obesity.
- Kidney: monitor kidney function and avoid NSAIDs.
Follow-up
See Mr. W. in 2 to 4 weeks with a repeat serum urate and kidney function, then regularly until his urate stays below 6 mg/dL. Long-term, the target is fewer flares and, eventually, none.
Reference
FitzGerald, J. D., Dalbeth, N., Mikuls, T., Brignardello-Petersen, R., Guyatt, G., Abeles, A. M., Gelber, A. C., Harrold, L. R., Khanna, D., King, C., Levy, G., Libbey, C., Mount, D., Pillinger, M. H., Rosenthal, A., Singh, J. A., Sims, J. E., Smith, B. J., Wenger, N. S., . . . Neogi, T. (2020). 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care & Research, 72(6), 744–760. https://doi.org/10.1002/acr.24180
