A 78 year old man is seen in the clinic for a painful swelling of the left elbow. Over the past year, he has had a few episodes of pain and swelling in his right knee and left foot, for which he received ibuprofen and once was treated with an antibiotic. His elbow is shown in the picture. He also has hypercholesterolemia and hypertension and is on simvastatin, hydrochlorothiazide and metoprolol.

He drinks several beers a day but does not smoke.

His exam is remarkable only for the appearance of his hands, similar to the picture shown.

• His labs reveal (normal ranges):
• WBC 11.4/cu mm (4-10/cu mm).
• Hb 13.5 g/dL (11-14g/dL).
• Platelets 96/cu mm (150-450/cu mm), AST 65 U/L (20-45 U/L), ALT 64 U/L (20-45 U/L).
• Creatinine 1.7 mg/dL (0.6-1.2 mg/dL)
• ESR 86mm/hr (0-20mm/hr)

What is the most appropriate next step, respectively?

Aspiration of the olecranon bursa was performed. Findings under polarized microscopy showed the presence of intracellular negatively birefringent crystals. Treatment consists of injection of steroids (in the absence of an obvious infection) into the olecranon bursa. In addition to intra-articular injections, other treatments for acute gout include NSAIDs, colchicine, and oral glucocorticoids. Urate-lowering therapy should not be initiated during an acute attack. If a patient is already on urate-lowering therapy or it was briefly interrupted, it should be continued or restarted.

Having established the diagnosis and provided relief for the acute problem what are the next steps in the management of this patient?

• The patient's serum uric acid level needs to be documented once the acute episode has resolved completely, as it is not uncommon for the serum uric acid level to be normal during an acute attack of gout. The patient's risk factors for hyperuricemia need to be addressed: alcohol intake (his intake is significant and may be a cause for his thrombocytopenia), and medications (hydrochlorothiazide) as well as lifestyle and dietary issues.
• Gout treatment is predicated upon comorbid conditions. His renal function is abnormal and would impact some treatments you might offer, including NSAIDs, which can adversely affect renal function, colchicine, which can lead to myelosuppression in renal insufficiency and urate lowering therapies such as allopurinol or febuxostat, which although not directly toxic to the kidney, needs to be dose titrated with respect to renal insufficiency. Febuxostat does not require dosage adjustment for a creatinine clearance greater than 30 cc/min. Dosing is not defined for creatinine clearance below 30 cc/min.
• In general, once urate lowering therapy is initiated with allopurinol or febuxostat, prophylactic therapy with NSAIDS, colchicine or glucocorticoids is continued for approximately six months, to prevent flares commonly seen during initiation of urate lowering therapy.
• Colchicine can cause significant diarrhea and should almost never be dosed in the "traditional" way of 0.6 mg every two hours for six doses or until the patient has diarrhea. It can be efficacious in twice daily dosing, but is more effective for the prevention of rather than treatment for gout. Intravenous colchicine is no longer available.
• The serum uric acid level should be monitored regularly during treatment, with dose titration until a target goal of less than 6.0 mg/dL is achieved.