Once again, it became important for our team to come up with a plan that he would adhere to and that would provide relief. We initiated febuxostat 40 mg daily. We convinced him to try taking just two colchicine tablets daily. We added vitamin C to his daily regimen to exploit its mild uricosuric effect. We kept him on a 5 mg dose of prednisone. Perhaps most importantly, we decided that his flares were so hard to control that we started him on anakinra injections three times a week.
He called our office three weeks later to tell us that he was thrilled to be flare free. We advised him to taper off the prednisone, but to keep taking the colchicine and febuxostat. We tapered the anakinra to a weekly injection.
Several weeks later, he remained symptom free, and his uric acid had dropped to 6.8 mg/dL. We increased his febuxostat to 80 mg daily.
We saw him three months later. His weight and blood pressure were stable. He was not drinking alcohol. He was taking febuxostat 80 mg daily and colchicine 0.6 mg BID. He was off corticosteroids and anakinra. The serum uric acid was 5.2 mg/dL. He tolerated this regimen well.
Our plan was to continue seeing him at four-month intervals to monitor therapy, and we eventually weaned him off colchicine.
We continued to spend time stressing the key educational aspects about gout. These are the points that most primary care doctors are often unable to review because of a lack of time or unfamiliarity with current guidelines for the care of hyperurecemia and gout. We emphasized that we were always available to help him manage an acute flare, but that he really needed to stay compliant with his current regimen and his current diet if he wanted to reduce the risk of future gouty flares and other complications of gout and hyperurecemia.
Conclusion
This case is probably not unusual for rheumatologists to see. Gout management is often crisis driven. There is episodic use of the healthcare system with limited or infrequent follow-up care. Often, patients’ compliance with care is limited by many factors. Rheumatologists can provide intensive, evidence-based care so that even refractory, difficult-to-treat cases of gout become manageable. It just takes time and patience.
Joan McTigue is a physician assistant for the rheumatology section of the VA Medical Center in Gainesville, Fla. She staffs the Gout Clinic there with rheumatology faculty and fellows of the University of Florida College of Medicine. In her spare time, she participates in expedition mountaineering.
