Management of Gout

Abstract

Mr R is a 57-year old man with a history of podagra (acute first metatarsal-phalangeal joint pain and swelling), hyperuricemia, and mild chronic kidney disease. An immigrant from Eastern Europe, Mr R worked as an engineer and is now retired. He lives with his wife and has several children. For many years, he has been a patient at a hospital-based primary care practice. He has a 60-packyear history of smoking but does not abuse alcohol or other drugs. He has no family history of gout, but his grandfather and father had renal disease of uncertain etiology.In 1993, Mr R experienced his first episode of podagra and was treated with indomethacin and an "injection into my toe." Five years later, his first measurement of uric acid was 7.7 mg/dL. Over the next 10 years, recurrent episodes of podagra were accompanied by uric acid levels as high as 9 mg/dL. Treatment with colchicine caused diarrhea without pain relief. He has adamantly refused further colchicine treatment. A consulting rheumatologist recommended that he use ibuprofen as his principal medication during acute episodes. In 2006, his serum creatinine level was first elevated to 1.3 mg/dL (with an estimated glomerular filtration rate of 57 mL/min/1.73 m 2 ); it later increased to 1.5 mg/dL but stabilized more recently at 1.3 mg/dL. He has had microalbuminuria, most recently with an albumincreatinine ratio of 442 mg/g (normal range, Ͻ30 mg/g). Aside from the presence of 2 cysts, kidney size and architecture were unremarkable on ultrasound and computed tomography.At the time of the elevation in creatinine, Mr R started therapy with allopurinol, 100 mg/d, which he continues. His uric acid levels range between 6 and 7 mg/dL. He has never had physical stigmata of gout other than intermittent swelling, redness, and pain in his great toe. He has not had recurrent symptoms since initiating allopurinol. Mr R has long-standing obesity. His height is 68 in (173 cm); weight, 258 lb (116 kg); and body mass index (calculated as weight in kilograms divided by height in meters squared), 39.2. His blood pressure has been mildly elevated. He has a long history of hyperlipidemia. Currently, his low-density lipoprotein cholesterol level is 172 mg/dL (ideal range, Ͻ129 mg/dL). He currently takes rosuvasta- CME available online at www.jamaarchivescme.com and questions on p 2154.Gout is an ancient disease. Despite significant advances in the understanding of its risk factors, etiology, pathogenesis, prevention, and treatment, millions of people with gout experience repeated attacks of acute arthritis and other complications. The incidence of gout is increasing, most likely reflecting increasing rates of obesity and other lifestyle factors, including diet. Comorbid conditions that often accompany gout, including chronic kidney disease and diabetes mellitus, present challenges for the management of gout. Using the case of Mr R, a 57-year-old man with a history of podagra, hyperuricemia, and mild renal insufficiency, the diagnosis and treatment of gout are discussed. For those with mode...

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