Gout in the elderly differs from classical
gout found in middle-aged men in several respects: it has a more equal gender distribution, frequent polyarticular presentation with involvement of the joints of the upper extremities, fewer acute gouty episodes, a more indolent chronic
clinical course, and an increased incidence of tophi. Long term
diuretic use in patients with
hypertension or congestive
cardiac failure,
renal insufficiency, prophylactic low dose
aspirin (
acetylsalicylic acid), and alcohol (
ethanol) abuse (particularly by men) are factors associated with the development of hyperuricaemia and
gout in the elderly. Extreme caution is necessary when prescribing nonsteroidal anti-inflammatory drugs (
NSAIDs) for the treatment of acute
gouty arthritis in the elderly.
NSAIDs with short plasma half-life (such as
diclofenac and
ketoprofen) are preferred, but these drugs are not recommended in patients with
peptic ulcer disease,
renal failure, uncontrolled
hypertension or
cardiac failure.
Colchicine is poorly tolerated in the elderly and is best avoided. Intra-articular and systemic
corticosteroids are increasingly being used for treating acute gouty flares in aged patients with medical disorders contraindicating
NSAID therapy.
Urate-lowering drugs are indicated for the treatment of hyperuricaemia and chronic
gouty arthritis. Uricosuric drugs are poorly tolerated and the frequent presence of renal impairment in the elderly renders these drugs ineffective.
Allopurinol is the
urate-lowering
drug of choice, but its use in the aged is associated with an increased incidence of both cutaneous and severe
hypersensitivity reactions. To minimise this risk,
allopurinol dose must be kept low. A starting dose of allopurinal 50 to 100mg on alternate days, to a maximum daily dose of about 100 to 300mg, based upon the patient's
creatinine clearance and serum
urate level, is recommended. Asymptomatic hyperuricaemia is not an indication for long term
urate-lowering
therapy; the risks of
drug toxicity often outweigh any benefit.