How should this older man with frequent attacks of gout be managed in the short and long term?
Hermann was a 68-year-old man with hypertension who had been having increasingly frequent attacks of gout. In the past, these attacks had been treated with colchicine with the predictable diarrhoea on each occasion. He had been prescribed allopurinol prophylaxis, starting at a dose of 25 mg daily and increasing by 25 mg every four to five days. When he had reached a dose of 100 mg daily after about two weeks, he remained at this dose.
A week later Hermann developed a severe respiratory infection that had precipitated both a massive nose bleed (requiring hospitalisation and cautery) and an exacerbation of his chronic obstructive pulmonary disease leading to a course of oral corticosteroids. As Hermann started to reduce his dose of oral corticosteroids, he developed a further painful and crippling attack of gout in both feet and, therefore, presented to his GP for management of this exacerbation. At the consultation, he had been taking the higher dose of allopurinol (100 mg daily) for two weeks.