When we saw him, he had no other medical problems, and his blood pressure and BMI were normal. His peripheral joints were all cool with full range of motion. He had no obvious tophi. His serum acid was 10.2 mg/dL. His renal function studies were normal. Risk factors included a family history of gout (i.e., his father) and heavy beer consumption, especially on weekends. He was a long distance truck driver.
We used this visit to educate him about gout, describing it as a chronic condition of excess urate burden, and emphasized our approach to management, stressing both short- and long-term goals. We hoped this would reduce future costly visits to the emergency department.
He had already started taking colchicine 0.6 mg twice daily. We initiated allopurinol 100 mg daily with the goal of reducing his serum uric acid to less than 6.0 mg/dL. With slow allopurinol titration and continued flare prophylaxis, his uric acid slowly fell to 8.0 mg/dL.
Unfortunately, EH stopped coming to the clinic. Not surprisingly, his allopurinol prescription ran out, and his uric acid was never checked again. This is not an unusual situation for patients suffering from episodic attacks of gout. They wait until the pain returns before seeking medical attention.
Five years later, he enrolled with a primary care physician. By then he was experiencing monthly gouty flares affecting the great toes, the mid foot, the knees and the elbows. His job as a long-haul truck driver was becoming compromised.
Follow-up
EH was referred back to our rheumatology clinic by his primary care physician. He admitted that he had not taken allopurinol or colchicine for years. Instead, he had continued to seek flare-based episodic care in various parts of the country. This often consisted of intramuscular corticosteroids or methylprednisone dosepacks. At our visit, he had a significant knee effusion. Aspiration and synovial fluid analysis confirmed the presence of monosodium urate crystals. His uric acid that day was 10.2 mg/dL. Erosive changes in his right great toe were seen on X-ray. Showing him these images proved quite useful.
Once again, colchicine 0.6 mg BID and allopurinol 100 mg daily were restarted. A tapering dose of prednisone was added to provide immediate relief. He was counseled to curtail his beer drinking, and he freely admitted that this would be his toughest task.
Three weeks later he returned, feeling better, but with a resolving right elbow effusion. His uric acid was 11.0 mg/dL He was taking only 5 mg of prednisone daily. He had stopped the allopurinol because of nausea and the colchicine because he was afraid it would cause diarrhea. He had experienced significant diarrhea during one of his prior emergency department visits when he was prescribed an excessive dose of colchicine.
