Main action points

Issue

Colchichine not controlling current gout flare-up

Recommendation

GP and pharmacist – Review counselling on newly diagnosed gout patients.

Patient – Allopurinol does not need to be stopped for subsequent gout attacks and can be taken as normal during these periods. If colchicine is still not effective for the next flare-up, consider requesting a switch to naproxen as this has previously been effective for pain. General advice for treating an acute attack includes keeping the joint cool, remaining adequately hydrated and to avoid knocking the affected joint.

Rationale

Mrs Thompson should not have initiated allopurinol and colchichine together because taking allopurinol can prolong an acute gout attack. Patients should wait two to three weeks after their first flare-up to commence allopurinol. This may not have been communicated by Mrs Thompson’s GP or the pharmacist at the time of dispensing.

Issue

Non-compliant with metformin

Recommendation

Patient – Planning ahead and preparing meals in advance can help when Mrs Thompson is unexpectedly busy. This will ensure she has healthy, well-balanced meals while also being able to take her metformin.

Rationale

Mrs Thompson is not eating regularly while she is caring for her ill husband. She often has to grab something ‘on the go’ and as a result she is sometimes missing doses of metformin. Not eating regularly will mean Mrs Thompson has poor glucose control. Having diabetes increases the risk of developing gout and her poorly managed blood glucose may be a contributing factor in developing the condition.

Issue

Allopurinol not effective to prevent flare-ups

Recommendation

GP – Monitor dose to ensure Mrs Thompson’s blood uric acid levels are low enough. Consider increasing dose if levels are too high. Take regular blood tests to monitor levels until an effective dose is found.

Patient – Continue to take as directed and attend regular blood tests to ensure current dose is the most appropriate.

Rationale

Allopurinol can cause acute gout attacks when it is initiated and can take one to two years before attacks cease. It is important to persevere with this treatment to prevent attacks in the future and reduce uric acid levels, which lead to gout.

Issue

Healthy living advice

Recommendation

Patient – Ensure diabetes is well-controlled and follow healthy living advice to reduce the frequency of gout attacks. Direct patient to helpful websites for diet and lifestyle advice, including the UK Gout Society's page.

Rationale

Foods high in purines are broken down into uric acid in the body and increase the risk of developing gout. They should therefore be avoided. High-purine foods include:

Red meat – beef, lamb and pork
Offal – liver and kidney
Oily fish.

Beer and spirits also increase uric acid levels in the body. Wine in moderation shouldn’t significantly increase the risk of developing gout.

Take regular exercise, preferably those which do not put a strain on joints eg swimming.

Maintain a healthy weight as this can reduce pressure on weight-bearing joints and reduce the number of acute attacks suffered.

Drink plenty of water to prevent crystals forming in the joints.

MUR case study: 65-year-old unsure over her gout

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