Gout should also be considered in elderly patients when attacks of acute pain and swelling are seen in osteoarthritic joints of the fingers, especially in patients who have renal disease or are on chronic diuretic therapy.
An older patient without a history of gout and without any obvious risk for gout or sign of a septic joint probably has pseudogout, which is caused by the deposition of calcium pyrophosphate dihydrate rather than monosodium urate. Pseudogout often strikes the wrist or the knee and does not commonly involve polyarticular attacks, as gout does.
Clinical experience has shown that with a suspicion of either gout or pseudogout, a short empiric course of anti-inflammatory treatment should be considered, said Dr. Rachow. "If it really is crystal induced, you’ll know in 12 hours and definitely within 24 hours" because the pain will begin to subside, he said.
"And, at that point, if you’ve started with a nonsteroidal anti-inflammatory and it’s working well, you can add a gastroprotective agent and continue the NSAID, reducing the dose once symptoms begin to improve. Or you can switch to colchicine."
"At your leisure, you can consider getting an x-ray," Dr. Rachow added, as detectable calcium deposits in the cartilage are typical of pseudogout.
If the anti-inflammatory treatment is "not working spectacularly well within 24 hours, you need to put the brakes on, close your office door, and think things over again," he said.
Facilities that have a sizable number of patients with frequent flares probably should have a nurse practitioner or of physician assistant trained to aspirate joints and arrange the logistics for sending out samples, Dr. Taler said.
The Longer Term
With a correct approach, "gout is eminently preventable and treatable in 90% of nursing home residents," said Dr. Weinstein. "The principles are studied, reported, and well described," he said. The American College of Rheumatology plans to release its first practice guidelines on the management of gout in 2012.
Decisions about managing acute attacks – whether to use NSAIDs, glucocorticoids, or oral colchicine – are rightly driven by the severity of gout and consideration of the patient’s coexisting illnesses and the drugs’ side effects. While NSAID use carries the risk of gastropathy, colchicine can cause diarrhea and other potentially serious side effects and should be avoided in patients who have renal or hepatic insufficiency.
Many clinicians consider colchicine a second-line therapy for acute gout, after NSAIDs or corticosteroids. In very elderly people, however, the treatment decision might be different. Dr. Weinstein said he worries about possible cardiac risks with the use of NSAIDs in very old patients. He has had success with the early use of low-dose colchicine in very elderly patients with reasonable kidney function, and he said that the drug "works best in the first 48-72 hours."
Parenteral corticosteroids, intra-articular injections, or even an oral prednisone taper are good options, he emphasized. Issues of whether and how to move from acute management of gout attacks to long-term urate-lowering therapy are taking on added significance in nursing homes as the prevalence of gout increases there.
Dr. Rachow recommended that hypouricemic therapy be initiated for patients who have documented hyperuricemia and a history of multiple attacks, and for patients who have developed tophi, which the therapy can dissolve.
It can even be considered for a frail, ill nursing home resident for whom a second gout attack would be unusually complicating and traumatic, said Dr. Rachow. "There may be residents who we can’t imagine having to hospitalize in the next year [for another gout attack], for whom we want to take possible recurrence out of the picture once and for all."
When it is deemed beneficial, the urate-lowering therapy must be undertaken with care, he emphasized. Dr. Rachow said that hypouricemic therapy should start only after an acute attack is completely resolved (or even 2-4 weeks after flare resolution), with cautious dosing and careful monitoring for adverse effects and, when possible, under the cover of a prophylactic anti-inflammatory drug. Low-dose colchicine has long been used to prevent flares associated with the lowering of urate.
Allopurinol, the xanthine oxidase inhibitor most commonly prescribed to lower urate levels, should be "started low and increased slowly" in older patients with renal impairment, Dr. Weinstein said. He advised beginning with 100 mg/day and increasing by 100 mg/day each month until the patient’s uric acid level is below 6 mg/dL.
Another xanthine oxidase inhibitor called febuxostat (Uloric) was approved in 2009 by the FDA for treatment of hyperuricemia in patients with gout, but its efficacy and safety compared with allopurinol is not fully established (N. Engl. J. Med. 2011;364:443-52). The new drug may have advantages, however, in that it appears to be safe without dose adjustment in patients with renal insufficiency, Dr. Weinstein said.