Rheumatology

Answer 6 Start colchicine and indomethacin twice daily. The patient was correctly started on allopurinol for tophaceous gout. However, many patients will stop taking allopurinol upon experiencing a flare. Attacks of gout frequently occur as the serum uric acid drops below the saturation level (ñ 6.7 mg/dL) and uric acid that has coated joints and tissues moves away from the affected sites to enter the circulation and exit the body. Any action that causes shifts in uric acid levels will enhance gout flares; therefore, allopurinol should not be stopped or adjusted during an attack. Before initiating any uric acid-lowering therapy for gout, it is important to explain to patients that therapy should not be discontinued without consulting a physician. Attacks of gout can be minimized with a prophylactic dose (0.6 mg) of colchicine twice daily (and in lower doses in patients with renal insufficiency) usually maintained for up to 6 months after initiating uric acid- lowering therapy.6 Most patients will not experience any gastrointestinal toxicity at this dose. Acetaminophen may help the patient with mild analgesia; however, it is unlikely to be strong enough to be effective. REFERENCES 6.  Kot TV, Day RO, Brooks PM. Preventing acute gout when starting allopurinol therapy: colchicine or NSAIDs? Med J Aust 1993;159:182-4. Click here to return to the questions

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