Managing Gout Flares in the Elderly: Practical Considerations
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Gout is common in the elderly, affecting an estimated 4.7 million people aged > 60 years in the USA alone. The incidence and prevalence of gout increases, and male predisposition to gout reduces, with increasing age. The elderly have more comorbidities, and gout manifests differently, with more frequent involvement of knees, ankles, and wrists at disease onset, systemic upset, and tophi. Comorbidities and polypharmacy make the management of gout flares challenging in this population. Intra-articular corticosteroid injection remains the treatment of choice for accessible joints, oral prednisolone is preferred over low-dose colchicine, and non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided. Xanthine oxidase inhibitors (XOI) remain the first-line treatment for hyperuricemia in the elderly. Arhalofenate, an emerging uricosuric anti-inflammatory drug, prevents gout flares while reducing serum urate. It may be particularly relevant in the treatment of gout in the elderly as they are unable to tolerate long-term colchicine for flare prophylaxis and frequently have contraindications to corticosteroids and NSAIDs. However, given its modest urate-lowering effect, it can only be used in combination with an XOI, and the safety and efficacy of this drug has not been examined in the elderly or in those with chronic kidney disease. Diuretics and beta-blockers should be discontinued where feasible, whereas low-dose aspirin can be continued if otherwise indicated.
Compliance with Ethical Standards
No funding was received for this study.
Conflict of interest
Dr. A. Abhishek has received departmental research grants from AstraZeneca and OxfordImmunotech.
- 5.Poiley J, Steinberg AS, Choi YJ, Davis CS, Martin RL, McWherter CA, et al. A Randomized, double-blind, active- and placebo-controlled efficacy and safety study of arhalofenate for reducing flare in patients with gout. Arthritis Rheumatol (Hoboken, NJ). 2016;68(8):2027–34. https://doi.org/10.1002/art.39684.CrossRefGoogle Scholar
- 6.Steinberg AS, Vince BD, Choi YJ, Martin RL, McWherter CA, Boudes PF. The pharmacodynamics, pharmacokinetics, and safety of arhalofenate in combination with febuxostat when treating hyperuricemia associated with gout. J Rheumatol. 2017;44(3):374–9. https://doi.org/10.3899/jrheum.161062.CrossRefPubMedGoogle Scholar
- 8.Atallah AN, Guimaraes JA, Gebara M, Sustovich DR, Martinez TR, Camano L. Progesterone increases glomerular filtration rate, urinary kallikrein excretion and uric acid clearance in normal women. Braz J Med Biol Res Revista brasileira de pesquisas medicas e biologicas. 1988;21(1):71–4.PubMedGoogle Scholar
- 23.Jordan KM, Cameron JS, Snaith M, Zhang W, Doherty M, Seckl J, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxf Engl). 2007;46(8):1372–4. https://doi.org/10.1093/rheumatology/kem056a.CrossRefGoogle Scholar
- 32.Khanna D, Khanna PP, Fitzgerald JD, Singh MK, Bae S, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. 2012;64(10):1447–61. https://doi.org/10.1002/acr.21773.CrossRefGoogle Scholar
- 34.Terkeltaub RA, Furst DE, DiGiacinto JL, Kook KA, Davis MW. Novel evidence-based colchicine dose-reduction algorithm to predict and prevent colchicine toxicity in the presence of cytochrome P450 3A4/P-glycoprotein inhibitors. Arthritis Rheum. 2011;63(8):2226–37. https://doi.org/10.1002/art.30389.CrossRefPubMedGoogle Scholar
- 35.Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060–8. https://doi.org/10.1002/art.27327.CrossRefPubMedGoogle Scholar
- 38.Man CY, Cheung IT, Cameron PA, Rainer TH. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial. Ann Emerg Med. 2007;49(5):670–7. https://doi.org/10.1016/j.annemergmed.2006.11.014.CrossRefPubMedGoogle Scholar
- 39.Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet (Lond Engl). 2008;371(9627):1854–60. https://doi.org/10.1016/s0140-6736(08)60799-0.CrossRefGoogle Scholar
- 41.Stamp LK, Chapman PT, Barclay ML, Horne A, Frampton C, Tan P, et al. A randomised controlled trial of the efficacy and safety of allopurinol dose escalation to achieve target serum urate in people with gout. Ann Rheum Dis. 2017;76(9):1522–8. https://doi.org/10.1136/annrheumdis-2016-210872.CrossRefPubMedGoogle Scholar
- 44.Choi YJ, Larroca V, Lucman A, Vicena V, Abarca N, Rantz T. Arhalofenate is a novel dual-acting agent with uricosuric and anti-inflammatory properties [abstract]. Arthritis Rheum. 2012;64(Suppl):S697.Google Scholar
- 46.Miner J, Tan PK, Hyndman D, Liu S, Iverson C, Nanavati P, et al. Lesinurad, a novel, oral compound for gout, acts to decrease serum uric acid through inhibition of urate transporters in the kidney. Arthritis Res Ther. 2016;18(1):214. https://doi.org/10.1186/s13075-016-1107-x.CrossRefPubMedPubMedCentralGoogle Scholar
- 48.Caspi D, Lubart E, Graff E, Habot B, Yaron M, Segal R. The effect of mini-dose aspirin on renal function and uric acid handling in elderly patients. Arthritis Rheum. 2000;43(1):103–8. https://doi.org/10.1002/1529-0131(200001)43:1<103:aid-anr13>3.0.co;2-c.CrossRefPubMedGoogle Scholar
- 50.McAdams DeMarco MA, Maynard JW, Baer AN, Gelber AC, Young JH, Alonso A, et al. Diuretic use, increased serum urate levels, and risk of incident gout in a population-based study of adults with hypertension: the Atherosclerosis Risk in Communities cohort study. Arthritis Rheum. 2012;64(1):121–9. https://doi.org/10.1002/art.33315.CrossRefPubMedPubMedCentralGoogle Scholar