A 61-year-old man comes to the office to follow up acute arthritis. He was seen at a nearby urgent care center 6 weeks ago for sudden-onset pain and swelling in the ankle. The patient was treated with an unknown analgesic with rapid relief of his pain. Since that time, his pain has resolved completely and he is now feeling well. Past medical history is notable for hypercholesterolemia, for which he takes atorvastatin. He also has a history of recurrent renal colic. On examination, his ankle appears normal with no redness, warmth, or swelling. Serum uric acid level is 9.8 mg/dL. Which of the following is the best agent for long-term management of this patient?

Question

A 61-year-old man comes to the office to follow up acute arthritis.  He was seen at a nearby urgent care center 6 weeks ago for sudden-onset pain and swelling in the ankle.  The patient was treated with an unknown analgesic with rapid relief of his pain.  Since that time, his pain has resolved completely and he is now feeling well.  Past medical history is notable for hypercholesterolemia, for which he takes atorvastatin.  He also has a history of recurrent renal colic.  On examination, his ankle appears normal with no redness, warmth, or swelling.  Serum uric acid level is 9.8 mg/dL.  Which of the following is the best agent for long-term management of this patient?

Quizplus · Accepted Answer

This patient had an episode of acute gouty arthritis that has responded to acute therapy. The decision now needs to be made whether to initiate long term preventive therapy. Patients who have only occasional episodes of gout may not need prophylactic treatment. However, uric acid-lowering medications can be helpful in patients with frequent episodes of gouty arthritis, chronic joint destruction, uric acid renal stones, or tophi. In addition to acute gout, this patient has had recurring episodes of likely uric acid stones and should be considered for prophylactic therapy. The preferred treatment to prevent recurrent attacks is xanthine oxidase inhibitors (eg, allopurinol, febuxostat), which decrease uric acid production. Prophylactic therapy is usually initiated during intercritical (between attacks) periods as acute changes in serum uric acid levels can worsen an acute attack. (Choice A) Septic arthritis can cause an acute monoarthritis but would be unlikely to respond to analgesics. (Choice B) Nonsteroidal antiinflammatory drugs (NSAIDs) act by inhibiting cyclooxygenase. NSAIDs are the first-line therapy for acute gouty arthritis and can prevent an acute flare while urate-lowering therapy is started. However, they are not normally used for long-term therapy due to risk of peptic ulcer. (Choice C) Oral or intraarticular glucocorticoids can be used for acute gout in patients who cannot tolerate NSAIDs or colchicine. However, they have significant long-term side effects. (Choice D) Lipoxygenase inhibitors (eg, zileuton) are oral anti-inflammatory medications used in the long-term management of asthma. They are not useful for treatment of gout. (Choice E) Uricosuric agents (eg, probenecid) are second-line drugs for chronic management of gout. These drugs increase renal excretion of uric acid and are therefore contraindicated in patients with a history of renal stones. Educational objective: Chronic uric acid-lowering therapy is recommended for patients with gout who have frequent gouty attacks, uric acid kidney stones, tophi, or chronic joint destruction from gout. Xanthine oxidase inhibitors are the preferred treatment. __________ References: Therapeutic approaches to chronic hyperuricemia and gout. (http://www.ncbi.nlm.nih.gov/pubmed/24696068)

A 61-Year-Old Man Comes to the Office to Follow Up