Event 2: Plan of Care

Summary of Findings

Mr. Clark, an 80-year-old man wearing glasses.
Mr. Clark

Mr. Clark refused to have needle aspiration of fluid in the great toe. Based on family and personal history, and physical examination,  a presumptive diagnosis of gout (also known as podagra when it involves the great toe) was made.

Management of Acute Pain in Gout

  • Mr. Clark was started on oral prednisolone daily for 5 days, to be taken with food
  • Monitor the CHF carefully
  • Monitor blood sugars
  • Evaluate need for blood pressure medications
  • See primary care provider the next day for follow up

Next day, symptoms are improved, and Mr. Clark continues the prednisolone for 4 more days, to return to primary care provider at the end of that time

Prednisolone for Acute Gout

  • Dosage for prednisolone is based on weight.
  • 0.5 mg/kg is recommended
  • Mr. Clark weighs 88.45 kg, therefore order is for 40 mg of prednisolone per day for 5 days, then tapered for 4 days

Long Term Follow Up of Mr. Clark

  • Careful review of current medications (will add more detail)
  • Urate-lowering therapy
  • Change in diuretic? Add losartan re: blood pressure?
  • Vitamin C?
  • Dietary changes (will add more)
  • Lifestyle changes (will add more; include exercise, etc.)
  • Follow up serum urate levels
  • Continue daily baby aspirin

Low Dose Aspirin and Gout

It is true that small doses of aspirin can increase the level of uric acid in the blood because it can impair the excretion of uric acid from the kidneys. However, this change is typically only noted when aspirin is taken in the usual over-the-counter doses (two 325 mg tablets every four hours). An extremely low dose of aspirin (75-81 mg per day), which is given, for example, for heart attack or stroke prevention, should not significantly alter the level of uric acid in the blood. Furthermore, even the higher doses mentioned should only cause an attack of gout in a person who already has the condition or is at risk for an attack, not in an individual with a normal metabolism.

Finally, it is interesting to note that aspirin has a very different effect on the blood level of uric acid when it is taken at very high doses, such as is prescribed by doctors for treating serious forms of inflammatory arthritis (like rheumatoid arthritis). In these very high doses, aspirin actually blocks the normal reabsorption of uric acid by a different part of the kidneys, thereby causing uric acid to be dumped out of the body in the urine and resulting in a lowering of the blood level of uric acid.

However, because of the effects of moderate and high-dose aspirin, which can alter the blood level of uric acid, aspirin and aspirin-containing products (see below) are generally avoided by people with known gout.

Common aspirin-containing products include Alka-Seltzer, Anacin, Arthritis Pain Formula, aspirin gum (Aspergum), Bayer, Bufferin, Darvon Compound, Doan's Pills, Ecotrin, Empirin, Excedrin, Fiorinal products, and Percodan products.

Would not want someone to think they should take him off his baby aspirin since he has other risk factors.




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