Anti-inflammatory doses of NSAIDs are effective and will shorten the duration of symptoms substantially. Seven to 10 days of indomethacin at a dose of 50 mg taken orally three times daily is the traditional choice, and though it is generally conceded that ibuprofen and naproxen also work well, no comparative trials have been performed. Elderly patients are at increased risk for adverse effects from NSAIDs, particularly those patients with severely reduced renal function, gastropathy, asthma, congestive heart failure, or other intravascularly depleted states. Gastric mucosal protection, using proton-pump inhibitors, and careful monitoring of fluid status, renal function, and mental status are of particular concern in this population.
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Because recent research indicates that COX-2 inhibitors have thrombotic potential and are contraindicated in patients at high risk for cardiovascular events or stroke, the extent to which they can be used in an elderly patient with an acute gouty attack is limited. A traditional NSAID in combination with a proton-pump inhibitor may be as effective as a COX-2 inhibitor in reducing the risk of gastroduodenal toxicity, however.
Corticosteroids—given either orally or intra-articularly—are an appropriate treatment for patients who can’t tolerate an NSAID. As long as a septic joint has been excluded, an intra-articular injection of 40–80 mg triamcinolone acetonide or 40 mg of methylprednisolone acetate will result in major improvement within 24 hours for most patients. Another option is a seven- to 10-day course of oral prednisone, starting with 40 mg on day one and reducing the dosage by 5 mg/day. Elderly patients taking oral prednisone should also receive adequate calcium, vitamin D, and a proton pump inhibitor for gastrointestinal protection, as well as close monitoring of blood pressure, glucose, and mental status.
If a patient has a history of frequent attacks or tophi, has a serum uric acid level higher than 12 mg/dl, or is consistently receiving high doses of diuretics, that person is at high risk for subsequent attacks and should receive prophylactic treatment with either a low-dose daily NSAID or a renally dosed oral colchicine.
Pseudogout
Pseudogout is the articular manifestation of calcium pyrophosphate dihydrate (CPPD) deposition, and this process is associated with aging as well as with various endocrinopathies, the most common of which is hyperparathyroidism. (See Table 3, below.) The shedding of CPPD crystals initiates an inflammatory process, and these crystals invoke an inflammatory response in much the same manner as uric acid crystals.
While the precipitants of a pseudogout attack are less well defined than those of gout, dehydration and joint surgery have both been identified as predisposing factors. The acute monoarticular pain and swelling (the knee is most common, followed by the ankle and then any other synovial joint) that ensues usually has a more insidious onset, and an X-ray may show chondrocalcinosis within the joint space. The diagnosis is confirmed by the demonstration of intracellular CPPD crystals in the aspirated joint fluid. Though less easily seen than monosodium urate crystals, rhomboidal crystals that display weakly positive birefringence under polarized light will be revealed with careful observation. Vitally important to the diagnosis of any crystal-associated arthritis is the exclusion of septic arthritis. To this end, conduct synovial fluid and blood cultures even if the suspicion of sepsis is low.
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Treatment goals for pseudogout center on the abatement of the current arthritis and the exclusion of an infected joint or a concurrent metabolic syndrome. NSAIDs are the mainstay of therapy for the management of pseudogout; they are prescribed in anti-inflammatory doses similar to those used in the treatment of gout. Corticosteroids can also be used, particularly an intra-articular injection, as long as infection has been excluded. As with any crystal arthropathy, a septic joint should be considered and treated in high-risk patients even before the results of the joint fluid cultures are available. (See Table 4, above.)