Rheumatology Case Challenge: Statin Use and Gout in a Man Put on NSAIDs by Locum Tenens Doc

Bruce M. Rothschild, MD


February 13, 2023

Similarly, the corticosteroid dosage was greater than needed for treatment of an acute flare. Although use of short-term corticosteroids in the management of gout is reasonable in this setting, long-term use for prophylaxis of acute attacks is controversial, given the many serious adverse effects, especially in a patient with coronary artery disease who already had pedal edema. As long as kidney disease status is no worse than stage 3B, continuing low-dose colchicine with close laboratory monitoring is reasonable. Use of NSAIDs for prophylaxis in a patient with stage 3B or worse renal disease and hypertension is controversial, and many would consider the drugs contraindicated. If low-dose colchicine is not tolerated, low-dose corticosteroids remain a cost-effective choice, despite the risks. Alternatively, IL-1 inhibitors have been used successfully, although their cost is a major concern.

Fluctuation in uric acid levels may be more responsible for flares than the actual levels themselves. Intervention with uric acid–lowering medications to reduce the risk for such flares is standard; however, this patient's allopurinol dose was inadequate (ie, it did not "treat to the target" of lowering the uric acid level to below 6 mg/dL). Allopurinol is usually initiated at 100 mg/d, and this daily dose is increased by 100 mg every month until the desired uric acid level reduction is achieved.[5] That may eventually require 600-800 mg/d.

Low-dose aspirin interferes with uric acid excretion, which produces hyperuricemia, and renal disease can complicate hyperuricemia. However, when low-dose aspirin is clinically indicated, it can be continued while allopurinol is administered to control hyperuricemia. Alternatives to low-dose aspirin to reduce platelet "stickiness," including NSAIDs, may be considered when clinically appropriate.[6] In the presence of polypharmacy, it is reasonable to assess hematologic, renal, and liver function within a week of initiation of a new medication.

A final consideration is the challenge to continuity of care related to locum tenens clinics, especially with respect to alternating assignments. Additionally, such clinics typically have constrained appointment "slots," long waiting lists for appointments, and very limited options for scheduling timely follow-up.