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Managing Gout Flares in the Elderly: Practical Considerations

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Abstract

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.

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Reproduced from Abhishek et al. [22] with permission

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References

  1. Kuo C-F, Grainge MJ, Mallen C, Zhang W, Doherty M. Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study. Ann Rheum Dis. 2014. https://doi.org/10.1136/annrheumdis-2013-204463.

    Google Scholar 

  2. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007–2008. Arthritis Rheum. 2011;63(10):3136–41. https://doi.org/10.1002/art.30520.

    Article  PubMed  Google Scholar 

  3. McCarty DJ, Hollander JL. Identification of urate crystals in gouty synovial fluid. Ann Intern Med. 1961;54:452–60.

    Article  CAS  PubMed  Google Scholar 

  4. Abhishek A, Valdes AM, Zhang W, Doherty M. Association of serum uric acid and disease duration with frequent gout attacks: a case-control study. Arthritis Care Res. 2016;68(10):1573–7. https://doi.org/10.1002/acr.22855.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google 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.

    Article  PubMed  Google Scholar 

  7. Dehlin M, Drivelegka P, Sigurdardottir V, Svärd A, Jacobsson LTH. Incidence and prevalence of gout in Western Sweden. Arthritis Res Ther. 2016. https://doi.org/10.1186/s13075-016-1062-6.

    Google 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.

    CAS  PubMed  Google Scholar 

  9. Nicholls A, Snaith ML, Scott JT. Effect of oestrogen therapy on plasma and urinary levels of uric acid. BMJ. 1973;1(5851):449–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Hak AE, Curhan GC, Grodstein F, Choi HK. Menopause, postmenopausal hormone use and risk of incident gout. Ann Rheum Dis. 2010;69(7):1305–9. https://doi.org/10.1136/ard.2009.109884.

    Article  PubMed  Google Scholar 

  11. Rothenbacher D, Primatesta P, Ferreira A, Cea-Soriano L, Rodriguez LA. Frequency and risk factors of gout flares in a large population-based cohort of incident gout. Rheumatology (Oxf Engl). 2011;50(5):973–81. https://doi.org/10.1093/rheumatology/keq363.

    Article  Google Scholar 

  12. Richette P, Clerson P, Périssin L, Flipo R-M, Bardin T. Revisiting comorbidities in gout: a cluster analysis. Ann Rheum Dis. 2015;74(1):142–7. https://doi.org/10.1136/annrheumdis-2013-203779.

    Article  PubMed  Google Scholar 

  13. ter Borg EJ, Rasker JJ. Gout in the elderly, a separate entity? Ann Rheum Dis. 1987;46(1):72–6.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hadler NM, Franck WA, Bress NM, Robinson DR. Acute polyarticular gout. Am J Med. 1974;56(5):715–9.

    Article  CAS  PubMed  Google Scholar 

  15. Getta B, O’Mahony PG. Atypical presentation of acute gout in an elderly patient. J Am Geriatr Soc. 2008;56(4):764–5. https://doi.org/10.1111/j.1532-5415.2008.01619.x.

    Article  PubMed  Google Scholar 

  16. Wilson ME, Wan SH, Beyder A, Osborn TG, Beckman TJ. Acute polyarticular gout presenting as delirium. J Clin Rheumatol Pract Rep Rheum Musculoskelet Dis. 2013;19(4):221–2. https://doi.org/10.1097/RHU.0b013e318293794f.

    Google Scholar 

  17. Abhishek A, Valdes AM, Jenkins W, Zhang W, Doherty M. Triggers of acute attacks of gout, does age of gout onset matter? A primary care based cross-sectional study. PLoS One. 2017;12(10):e0186096. https://doi.org/10.1371/journal.pone.0186096.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Singh JA, Yu S. Gout-related inpatient utilization: a study of predictors of outcomes and time trends. Arthritis Res Ther. 2016;18:57. https://doi.org/10.1186/s13075-016-0936-y.

    Article  PubMed  PubMed Central  Google Scholar 

  19. He W, Phipps-Green A, Stamp LK, Merriman TR, Dalbeth N. Population-specific association between ABCG2 variants and tophaceous disease in people with gout. Arthritis Res Ther. 2017. https://doi.org/10.1186/s13075-017-1254-8.

    Google Scholar 

  20. Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol. 1985;24(2):155–7.

    Article  CAS  PubMed  Google Scholar 

  21. Mitnala S, Phipps-Green A, Franklin C, Horne A, Stamp LK, Merriman TR, et al. Clinical and genetic features of diuretic-associated gout: a case-control study. Rheumatology. 2016;55(7):1172–6. https://doi.org/10.1093/rheumatology/kew018.

    Article  PubMed  Google Scholar 

  22. Abhishek A, Roddy E, Doherty M. Gout - a guide for the general and acute physicians. Clin Med (Lond). 2017;17(1):54–9. https://doi.org/10.7861/clinmedicine.17-1-54.

    Article  PubMed  Google 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.

    Article  Google Scholar 

  24. Logan JA, Morrison E, McGILL PE. Serum uric acid in acute gout. Ann Rheum Dis. 1997;56(11):696–7. https://doi.org/10.1136/ard.56.11.696a.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Dalbeth N, Doyle AJ. Imaging of gout: an overview. Best Pract Res Clin Rheumatol. 2012;26(6):823–38. https://doi.org/10.1016/j.berh.2012.09.003.

    Article  PubMed  Google Scholar 

  26. Newberry SJ, FitzGerald JD, Motala A, Booth M, Maglione MA, Han D, et al. Diagnosis of gout: a systematic review in support of an american college of physicians clinical practice guideline. Ann Intern Med. 2017;166(1):27–36. https://doi.org/10.7326/m16-0462.

    Article  PubMed  Google Scholar 

  27. Loffler C, Sattler H, Peters L, Loffler U, Uppenkamp M, Bergner R. Distinguishing gouty arthritis from calcium pyrophosphate disease and other arthritides. J Rheumatol. 2015;42(3):513–20. https://doi.org/10.3899/jrheum.140634.

    Article  PubMed  Google Scholar 

  28. Abhishek A, Doherty M. Update on calcium pyrophosphate deposition. Clin Exp Rheumatol. 2016;34(4 Suppl 98):32–8.

    PubMed  Google Scholar 

  29. Ea HK, Liote F. Diagnosis and clinical manifestations of calcium pyrophosphate and basic calcium phosphate crystal deposition diseases. Rheum Dis Clin North Am. 2014;40(2):207–29. https://doi.org/10.1016/j.rdc.2014.01.011.

    Article  PubMed  Google Scholar 

  30. Kohn NN, Hughes RE, Mc CD Jr, Faires JS. The significance of calcium phosphate crystals in the synovial fluid of arthritic patients: the “pseudogout syndrome”. II. Identification of crystals. Ann Intern Med. 1962;56:738–45.

    Article  CAS  PubMed  Google Scholar 

  31. Dieppe PA, Doherty M, Macfarlane DG, Hutton CW, Bradfield JW, Watt I. Apatite associated destructive arthritis. Br J Rheumatol. 1984;23(2):84–91.

    Article  CAS  PubMed  Google 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.

    Article  CAS  Google Scholar 

  33. Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castañeda-Sanabria J, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29–42. https://doi.org/10.1136/annrheumdis-2016-209707.

    Article  CAS  PubMed  Google 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.

    Article  CAS  PubMed  Google 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.

    Article  CAS  PubMed  Google Scholar 

  36. Wason S, Mount D, Faulkner R. Single-dose, open-label study of the differences in pharmacokinetics of colchicine in subjects with renal impairment, including end-stage renal disease. Clin Drug Investig. 2014;34(12):845–55. https://doi.org/10.1007/s40261-014-0238-6.

    Article  CAS  PubMed  Google Scholar 

  37. Wechalekar MD, Vinik O, Schlesinger N, Buchbinder R. Intra-articular glucocorticoids for acute gout. Cochrane Database Syst Rev. 2013. https://doi.org/10.1002/14651858.CD009920.pub2.

    PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  CAS  Google Scholar 

  40. Jackson RL, Hunt B, MacDonald PA. The efficacy and safety of febuxostat for urate lowering in gout patients ≥65 years of age. BMC Geriatr. 2012;12:11. https://doi.org/10.1186/1471-2318-12-11.

    Article  CAS  PubMed  PubMed Central  Google 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.

    Article  PubMed  Google Scholar 

  42. Hande KR, Noone RM, Stone WJ. Severe allopurinol toxicity. Description and guidelines for prevention in patients with renal insufficiency. Am J Med. 1984;76(1):47–56.

    Article  CAS  PubMed  Google Scholar 

  43. Lavan BE, McWherter C, Choi YJ. Arhalofenate, a novel uricosuric agent, is an inhibitor of human uric acid transporters [abstract]. Ann Rheum Dis. 2013;71(Suppl 3):450–1.

    Article  Google 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 

  45. Martinon F, Petrilli V, Mayor A, Tardivel A, Tschopp J. Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature. 2006;440(7081):237–41. https://doi.org/10.1038/nature04516.

    Article  CAS  PubMed  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.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Segal R, Lubart E, Leibovitz A, Berkovitch M, Habot B, Yaron M, et al. Early and late effects of low-dose aspirin on renal function in elderly patients. Am J Med. 2003;115(6):462–6.

    Article  CAS  PubMed  Google 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.

    Article  CAS  PubMed  Google Scholar 

  49. Choi HK, Soriano LC, Zhang Y, Rodríguez LAG. Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. BMJ. 2012;344:d8190. https://doi.org/10.1136/bmj.d8190.

    Article  PubMed  PubMed Central  Google 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Division of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK

    Abhishek Abhishek

  2. Academic Rheumatology, Clinical Sciences Building, City Hospital Nottingham, Nottingham, NG5 1PB, UK

    Abhishek Abhishek

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Correspondence to Abhishek Abhishek.

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Dr. A. Abhishek has received departmental research grants from AstraZeneca and OxfordImmunotech.

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Abhishek, A. Managing Gout Flares in the Elderly: Practical Considerations. Drugs Aging 34, 873–880 (2017). https://doi.org/10.1007/s40266-017-0512-4

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