8.2 Gout, Pain & Rheumatologic Care

Acute Gout Flare Management

Gout is a monosodium urate crystal arthropathy presenting as sudden, exquisitely painful monoarthritis — classically the first metatarsophalangeal joint (podagra). Before treating a first-ever hot swollen joint, consider the red flag of septic arthritis, which may need joint aspiration and urgent admission. Once gout is established as the diagnosis, the care principle is treat the flare early and aggressively, with the agent chosen according to comorbidities:

• NSAID (e.g., naproxen or indomethacin at full anti-inflammatory dose) if there is no renal impairment, peptic ulcer disease, or cardiovascular contraindication; add a proton pump inhibitor for gastroprotection where risk factors exist.
• Colchicine at low dose — for example 1 mg then 0.5 mg one hour later, or 0.5 mg two to three times daily — is as effective as historical high-dose regimens with far less gastrointestinal toxicity. Reduce the dose in renal impairment and beware interactions with clarithromycin, ciclosporin, and statins, which can cause colchicine accumulation.
• Corticosteroid — oral prednisolone (e.g., 30–35 mg daily for 3–5 days) or intra-articular injection — is preferred when NSAIDs and colchicine are unsuitable, such as in chronic kidney disease.

The most examined rule: in a patient already established on allopurinol, do NOT stop it during a flare — treat the flare on top and continue the urate-lowering drug unchanged, because interrupting it causes urate fluctuations that can prolong the attack. Traditional practice also avoided starting urate-lowering therapy mid-flare; current American College of Rheumatology guidance conditionally permits initiation during a flare, but the unchanging exam point is that an established user must never have it stopped. Adjunctive measures include rest, ice packs, and simple analgesia.

Urate-Lowering Therapy (ULT)

Offer long-term ULT to patients with recurrent flares, tophi, chronic kidney disease, urolithiasis, or diuretic-driven hyperuricaemia.

• Allopurinol first line, start-low-go-slow: begin at 100 mg daily (50 mg daily in significant renal impairment) and titrate every 2–4 weeks against the serum urate. Under-dosing is the most common real-world reason for treatment failure.
• Treat-to-target serum urate: below 360 µmol/L (6 mg/dL) for most patients; below 300 µmol/L (5 mg/dL) in severe disease with tophi or frequent flares, to accelerate crystal dissolution. Check urate a few weeks after each dose change and periodically once at target; therapy is usually lifelong, and adherence is the main determinant of success.
• HLA-B*58:01 screening: carriers have a much higher risk of allopurinol hypersensitivity syndrome, a potentially fatal severe cutaneous reaction. Screening before initiation is recommended in high-risk ethnicities — Han Chinese, Thai, Korean, African ancestry, and some South Asian and Middle Eastern populations — making it directly relevant to UAE practice. Counsel every patient to stop allopurinol and seek urgent care at the first sign of rash.
• Febuxostat is the usual alternative when allopurinol is not tolerated or ineffective, but use with cardiovascular caution — the CARES trial showed higher cardiovascular mortality in patients with established cardiovascular disease.
• Flare prophylaxis on initiation: starting or up-titrating ULT transiently increases flares, so co-prescribe colchicine 0.5 mg daily (or a low-dose NSAID) for 3–6 months and explain why, so the patient does not abandon therapy when an early flare occurs.
• Lifestyle: reduce beer and spirits, purine-rich foods (organ meats, certain seafood), and sugar-sweetened drinks; encourage weight loss, good hydration, and review of diuretic therapy where an alternative exists.

Osteoarthritis versus Rheumatoid Arthritis

For OA, NICE-style care emphasises therapeutic exercise and weight management, topical NSAIDs first for knee and hand disease, and the lowest oral NSAID dose for the shortest time with PPI cover when gastrointestinal risk factors exist; paracetamol has only a limited role. For RA, disease-modifying antirheumatic drugs (DMARDs) alter the disease course and must be started early by a specialist. Methotrexate is the anchor drug; other conventional options include sulfasalazine, hydroxychloroquine, and leflunomide (also teratogenic), with biologic DMARDs reserved for inadequate response after infection screening. Critical pharmacist counseling for methotrexate: taken once weekly on the same day each week (inadvertent daily dosing has caused fatal toxicity), co-prescribed with folic acid taken on a different day, with baseline and regular monitoring of full blood count, liver function tests, and renal function; it is contraindicated in pregnancy, so contraception counseling is essential. NSAIDs and short corticosteroid courses relieve RA symptoms only — they do not modify disease — and chronic NSAID use requires gastrointestinal, cardiovascular, and renal risk assessment.

Chronic Pain and Opioid Stewardship

• Build care on multimodal non-drug approaches: structured physical activity, physiotherapy, psychological therapies such as cognitive behavioural therapy, weight management, and sleep hygiene.
• Opioids are not first-line for chronic non-cancer pain, and there is little evidence of long-term benefit. If trialled, apply stewardship: lowest effective dose, time-limited course, agreed functional goals, and regular face-to-face review.
• Tapering: when harms outweigh benefits, reduce gradually — for example around 5–10% of the dose every 2–4 weeks, individualised to the patient — with support to minimise withdrawal and flare anxiety.
• Naloxone provision: offer or discuss take-home naloxone for patients on high opioid doses, those combining opioids with benzodiazepines or other sedatives, or those with a history of opioid use disorder, where local availability permits, and educate household members on recognising opioid-induced respiratory depression.
• Screen for misuse: early refill requests, escalating doses, sedation, and obtaining opioids from multiple prescribers. In the UAE context, note that tramadol and stronger opioid analgesics are tightly controlled medicines — prescribing and dispensing rules, including prescription validity and record-keeping, are strictly enforced by health authorities.