A Novel Intervention For The Treatment Of Gout In An Elderly Rehabilitation Patient

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Acute gouty flares are common in the acute rehabilitation hospital population especially in those patients who have undergone surgery or who have had fluid imbalances. We present a case of an 88-year-old man with acute renal failure and decreased mobility who developed gout in both knees and ankles and left great toe. This was his third gouty episode in less than a month, and it greatly hindered his rehabilitation progress. Colchicine and steroids did not provide sustained relief. NSAIDS were contraindicated because of the patient's concomitant renal failure. However, after 2 doses of dronabinol the patient reported pain relief within one day. Afterwards, he had no further gouty pain for 3 weeks under inpatient observation, and he was fully able to participate in therapy. In elderly patients in whom NSAIDS are contraindicated and colchicine and steroids do not provide sustained relief, dronabinol can be an effective way of treating gout with rapid onset of action and minimal side effects.

PT, an 88 y/o male with history of DJD and gout, was admitted to a tertiary acute care hospital with obstructive uropathy secondary to BPH, E. coli UTI, and acute renal failure. PT developed left foot pain, low grade fevers and an elevated WBC count to 16.7. He was diagnosed with a gouty flare 2 days before discharge and was started on colchicine 0.6 mg po Q.D. with resolution of the fevers and foot pain. At discharge from the acute care hospital PT's BUN/Cr were 68/2.7.

PT was admitted to a rehabilitation hospital for acute inpatient rehabilitation with deconditioning. He was assessed daily with Visual Analog Pain Scales (VAS, 0 = no pain, 10 = severe intense pain) and had 0/10 pain for the first 7 days of admission. 9 days after starting colchicines (day 8), the patient developed pain in both knees and ankles and the left great toe and reported pain on the VAS of 4/10. PT was seen by rheumatology and was diagnosed with an acute gouty flare. Bilateral knee and ankle plain films were taken. Ankle films showed soft tissue swelling and knee films showed tricompartmental DJD. The patient's left great toe was injected with 20 mg of triamcinolone and 0.5 ml of lidocaine. PT's hydrochlorothiazide (HCTZ) was discontinued. Two days after the injection PT's joint pain resolved. He remained pain free for 4 days. He was then transferred to the acute care hospital for treatment of a deep venous thrombosis (DVT). While he was treated for the DVT his BUN/Cr decreased to 30/1.7 and he was restarted on triamterine/HCTZ and furosemide.He returned to the rehabilitation hospital after 4 days and was continued on colchicine. However, after 7 days in the rehabilitation hospital, PT again developed pain in his bilateral lower extremities which limited his participation in therapy. Furthermore, he developed nausea and anorexia. Dronabinol 2.5 mg po BID was started for nausea and appetite stimulation. After 2 doses of dronabinol the patient reported a VAS score of 0/10 in his bilateral lower extremities.

The dronabinol was continued for 5 days. PT's renal failure worsened and his diuretics were discontinued. His BUN/Cr increased to 47/3.0. The PT's fluid status was tenuous and he required hydration and diuresis for renal failure. PT developed severe hematuria and he was readmitted to the acute care hospital for treatment. PT was readmitted to the rehabilitation hospital for continued therapy after 5 days in the acute care hospital. He was able to fully participate in his rehabilitation program and he remained free of gouty pain for a total of 4 weeks of direct inpatient observation.

Conclusion: For people at high risk of GI bleed or renal failure a short course of dronabinol is an option to consider if other treatments fail. Dronabinol has anti-inflammatory effects through the prostaglandin system.

Source: Gout Poster — School of Medicine at the University of Virginia