Case: assessment and new treatment
Mr. M’s joint symptoms were treated with a local corticosteroid injection after a culture of the synovial fluid proved negative for bacterial infection. He was switched from valsartan/hydrochlorothiazide to valsartan and a calcium channel blocker, and his dose of allopurinol was gradually titrated upward over a period of weeks.
The patient was instructed to take an oral corticosteroid for acute flares, while his CBC and creatinine clearance were monitored closely. Mr. M initially experienced an acute flare when the allopurinol dose was increased but had no flares in the past 5 months. He tolerated allopurinol well, and treatment achieved a serum uric acid level ranging from 5.2 mg/dL to 5.8 mg/dL. Mr. M agreed to have his serum uric acid level checked every 6 months.
In this patient, subtracting a thiazide diuretic plus adding daily treatment with allopurinol was effective in achieving a uric acid level <6.0 mg/dL. Comorbidities such as CKD, HTN, CVD, and DM are common in patients with hyperuricemia. Target serum uric acid levels are the same in patients with or without comorbidities; however, the choice of serum urate-lowering drug and dosage may need to be altered.
Often, first-line therapies are contraindicated or not tolerated in patients with these comorbidities. Corticosteroids are increasingly replacing NSAIDs and colchicine for the treatment of acute gout flares because they have little effect on kidney function. In Mr. M, if the uric acid level did not fall to <6.0 mg/dL (even if it fell to within the reference range), the decision would have to be made to either increase the dose of allopurinol or change therapy. In this circumstance, febuxostat is an alternative to allopurinol, as it is in patients with allopurinol intolerance or hypersensitivity.
Febuxostat does not require dose adjustment for patients with impaired kidney function. Pegloticase is an important new therapeutic agent for individuals with severe gout in whom allopurinol and febuxostat have not been tolerated or effective.
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