Ask the Doctors January 2018 Issue

Ask The Doctors: January 2018

Dr. Steven Maschke

Arthritis Advisor Editor-in-Chief Steven Maschke, MD, Department of Orthopaedic Surgery, Cleveland Clinic Orthopaedic & Rheumatologic Institute.

Q: I just had my first gout attack. Do I need to take chronic medication to prevent the next attack? I would like to avoid the next one. It was painful.

A: If you want to prevent the next attack, medication is indicated. If you choose not to use medication, when would the next attack occur? In 78 percent of cases, a second gout attack occurs within six months to two years of a first attack. This means that about 22 percent of people won’t have a second attack for over two years. So you have to ask yourself whether you want to take a medicine every day to prevent a second attack, or start treatment for acute gout early in the next attack. This is really a judgment call.

Certain factors make the next attack more likely, including use of diuretic drugs, kidney disease, drinking alcohol, eating foods such as organ meats, and obesity. If you modify these then you can reduce the risk of another gout attack.

Gout attacks start with excessive amounts of uric acid in the blood. Uric acid usually is eliminated from the body in urine. But some people don’t get rid of enough of it, causing it to remain in the blood. When levels get too high, it can settle in joints and tendons. It can then break down into the crystals that cause the red, hot, swollen and painful joint of a gout attack.

The management of gout involves treating the attack itself by relieving symptoms. This may include nonsteroidal anti-inflammatory drugs or the drug colchicine (Colcrys®). Over the long term, the goal is to prevent any flare-ups. This usually involves medication, such as allopurinol (Zyloprim®) or febuxostat (Uloric®), to lower uric acid levels. You probably will need to take these over the long term.

Q: When I was diagnosed with rheumatoid arthritis my doctor gave me methotrexate and a 10-mg dose of prednisone. Since then the prednisone was reduced to 5 mg. Should I be worried about any effect on my bones?

A: Corticosteroid drugs (including prednisone) can potentially cause osteoporosis. The lower the dose, the less the risk. But in many people (especially women), even low doses can cause bone loss.

The American College of Rheumatology (ACR) recently issued a guideline about corticosteroid use and osteoporosis. It recommends that everyone taking more than 7.5 mg a day of a corticosteroid also take an osteoporosis medication. For adults over age 40 who take a corticosteroid at a dose lower than 7.5 mg, a tool called FRAX® is used to determine risk for fracture in the next 10 years to make treatment decisions. FRAX takes several factors into account, including your age, gender, history of fractures and score on a bone density test. As long as you continue taking a corticosteroid, a bone density test should be repeated every one to two years.

Everyone taking a corticosteroid should get the recommended amounts of calcium and vitamin D. For those deemed at low risk for fracture, this may be enough if the bone density is stable. For those at moderate to high risk for fracture, or with corticosteroid doses greater than 7.5 mg, the ACR recommends adding a medication such as a bisphosphonate or denosumab (Prolia®). These drugs decrease bone resorption, thus increasing bone mass.

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