CHAPTER 39 MUSCULOSKELETAL DISORDERS
Practice of Geriatrics
CHAPTER 39 MUSCULOSKELETAL DISORDERS
Evan Calkins, M.D., and Adrian O. Vladutiu, M.D., Ph.D., F.A.C.P.
Classification and Pathophysiology
Specific Clinical Entities
Soft Tissue Rheumatism: Medical Orthopedics
CLASSIFICATION AND PATHOPHYSIOLOGY
Aches and pains in the musculoskeletal system constitute the most frequent complaints of older persons (Fig. 39-1) and account for a very significant segment of the practice of primary care physicians caring for patients in this age group. The causes of these complaints fall into three categories: (1) the classic rheumatic diseases, (2) conditions not generally regarded as rheumatic in nature whose clinical manifestations are expressed in the musculoskeletal system, and (3) a wide range of musculoskeletal disorders, primarily localized in nature, that fall under the general category of “soft tissue rheumatism.” The process of aging is accompanied by an increased frequency of conditions in all three of these categories.
Figure 39-1 Morbidity from top ten chronic conditions among the elderly. Relative frequency of most common chronic conditions among persons aged 65 and older. (From National Center for Health Statistics: Current estimates from the National Health Interview Survey: United States, 1986. Vital and Health Statistics Series 10, No. 164, 1987.)
Among the classic rheumatic diseases, certain entities, such as Still’s disease, Reiter’s disease, and new-onset ankylosing spondylitis, occur exclusively among young people and do not need to be considered in the differential diagnosis in older persons. In contrast, many other conditions, such as polymyalgia rheumatica, giant cell arteritis, Sjögren’s syndrome, and calcium pyrophosphatase deposition disease, are rarely seen among young persons and occur primarily or exclusively in the older population.1 Rheumatoid arthritis and gout occur in persons at many stages of life but are seen with increasing frequency in the later years. While osteoarthritis has its origins in early life (through genetic determinants, developmental problems affecting posture, and traumatic injuries), it rarely emerges as a significant clinical problem in persons under 40 years of age. However, it affects an estimated 80% of people aged 70 and older. Thus, there is a close interface between many of the classic rheumatic diseases and the process of aging.
At all stages of life, but especially among older patients, a number of disorders, not usually regarded as rheumatic in nature, are manifested by musculoskeletal symptoms or accentuate the symptoms of coincidental rheumatic disorders. Some of these, osteoporosis and Paget’s disease, for example, are disorders of the musculoskeletal system. Others, such as metastatic carcinoma and multiple myeloma, involve the skeletal system secondarily. Still others are disorders of the endocrine system. In addition to causing loss of skeletal calcium, hyperthyroidism is often associated with constitutional manifestations resembling rheumatoid arthritis and accentuates the symptoms, especially the constitutional symptoms, of the latter disease. Similarly, in a person with long-standing rheumatoid arthritis who exhibits progressive slowing of the locomotor system and gruffness of the voice, it is all too easy to attribute these symptoms to the rheumatoid process, failing to recognize the simultaneous presence of myxedema, treatment of which almost always yields significant improvement in the symptoms of rheumatoid arthritis.
Finally, and of special importance, there is the range of localized entities such as bursitis, tendonitis, muscle strain, fasciitis, fibromyalgia, and the various conditions leading to low back pain, all of which occur with increasing frequency in the older age group. Indeed, it is surprising that anyone can live out his allotted years without being afflicted by one condition or another that leads to musculoskeletal pain.
The multiplicity of musculoskeletal disorders, often in multiples, that afflict almost all older people lends a quality of nonspecificity to musculoskeletal symptoms among older patients that is rarely seen in the young. When young people present with pain in the joints, the problem is apt to fall within the framework of either a traumatic injury or one of the classic rheumatic disorders. When an older person complains of soreness and stiffness of the bones and joints, the cause is as apt to be metastatic carcinoma, osteoporosis, Paget’s disease, an endocrinopathy, or a neurologic disorder such as Parkinson’s disease as it is a classic rheumatic disease. If one adds the range of problems that are secondary to efforts to treat these conditions, and the influence that these disorders have on the functional capacity, independence, and emotional well-being of older people, one gains a perspective on the importance and complexity of musculoskeletal symptoms and disorders in the older segment of one’s practice.
Even in a busy primary care office, it is preferable to obtain a history with the patient fully clothed and sitting in a comfortable chair rather than perched on an examining table. The history of the present illness should start with the patient’s earliest experience with musculoskeletal symptoms. These initial manifestations may prove more helpful in establishing a diagnosis than more recent symptoms because the latter are influenced by a variety of secondary processes.
As one attempts to differentiate a local or structural abnormality in the musculoskeletal system from a systemic condition, it is important to inquire carefully about the presence of constitutional symptoms such as fatigue, weight loss, and vasomotor instability resembling Raynaud’s phenomenon, which are characteristic not only of many of the classic rheumatic diseases but also of metastatic carcinoma and multiple myeloma. One would not expect to encounter these symptoms in patients with osteoarthritis or gout unless they were due to an independent co-morbid systemic disease. It is particularly important to inquire specifically about the presence and duration of morning stiffness. Stiffness lasting for several hours or throughout the day is highly characteristic of rheumatoid arthritis, polymyalgia rheumatica, and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome. It is not characteristic of osteoarthritis, septic arthritis, or gout.
After obtaining a history, it is important to watch the patient as he or she rises from the chair and walks around the room a bit, wearing shoes. Following this, the patient can undress as appropriate and climb onto the examining table. Rather than attempting to help, it is useful to watch the patient to obtain important information about the patient’s functional status. For a patient with diffuse musculoskeletal symptoms it is important to carry out a complete physical examination including examination of the skin, lymph nodes, breasts, abdomen, and rectum plus a basic neurologic examination.
In interpreting the laboratory data,2 two points should be kept in mind. First, the process of aging itself yields values in some tests that would be regarded as abnormal in a younger person. For example, the erythrocyte sedimentation rate (ESR) reaches values of 30 to 35 mm in 1 hour in many healthy persons aged 80 or older.2 Both rheumatoid factor (RF) and antinuclear antibodies (ANA), in low titer, are present in many persons aged 70 or older, including those with no rheumatic or other symptoms of definable illness.2 Thus, the presence of RF in a titer of 1:64 (1280 IU) or ANA in a titer of less than 1:120 has no diagnostic or prognostic significance in a person aged 75 or older. In persons with slightly higher values in these tests, the interpretation should be made in the light of the clinical symptomatology, as discussed later in this chapter.
It is important to order laboratory procedures judiciously and properly. For example, for optimal interpretation of radiographs of the knee, it is essential to request specifically that the anteroposterior (AP) view be obtained with the patient standing so that the space between the surfaces of the femur and the tibia can be interpreted correctly as indicative of the depth of the interposed cartilage. To request an AP view of the knee without specifying the standing position will result in a radiograph that is of little or no value to a consulting rheumatologist or orthopedist and will almost surely have to be repeated. The lateral view of the knee, obtained to evaluate the patellofemoral interface, should be obtained in a supine position. The standing position is also helpful when obtaining AP views of the hips.
SPECIFIC CLINICAL ENTITIES
Osteoarthritis (OA) is by far the most common musculoskeletal disorder of older people. Osteoarthritis of the hands, especially the distal interphalangeal joints but also the proximal interphalangeal joints, carpometacarpal joint of the thumb and wrists, and osteoarthritis of the hips, knees, and spine are all seen with increasing frequency in persons of advanced age, but may occur independently of each other. Although there is general agreement that the focal point of the osteoarthritic process is the joint cartilage, we still do not have a clear understanding of the pathogenetic mechanisms. Although patients frequently have a history of repeated trauma or overuse of a given joint, an abnormality in the joint cartilage, sometimes occurring as a familial tendency, is an important contributing factor.
Once it has set in, osteoarthritis, especially arthritis of the knee or hip, is a seriously disabling disorder that is associated with several patterns of pain. With osteoarthritis of the knees, for example, some people experience pain with every step they take, while others complain of crampy pain in the leg muscles after walking a short distance—a few hundred yards. Many patients with osteoarthritis of the knees experience pain at night. This may consist of severe boring pain in the knees themselves or diffuse cramps in the adjacent muscles.
Physical examination of the knee in severe cases reveals any or all of the following: bony thickening, decreased range of motion, crepitus on motion, weakness of the quadriceps muscles, flexion deformity, malalignment (subluxation) of the joint, lateral instability, synovial thickening, and, at times, effusion, with warmth and tenderness. The joint fluid exhibits decreased viscosity and a low white cell count (usually less than 5000/mm3). The process in the hip, shoulder, ankle, and wrist follows a generally similar pattern. In the wrist, the synovial thickening is constricted by the carpal ligaments, resulting, in many cases, in carpal tunnel syndrome.
TREATMENT OF OSTEOARTHRITIS
Analgesic Drugs. Treatment of osteoarthritis of the large joints involves use of analgesic drugs, basic modalities of physical therapy, additional support through use of a cane or walker and, at times, surgery.3,4 The mainstay of pharmacologic therapy is acetaminophen. The dose must be individualized, with lower doses prescribed for persons with any form of renal disease. Although the drug may be given in doses as high as 4000 mg/day, we usually limit it to 2000 mg/day in older people because higher doses may produce a sense of grogginess and an increased potential for renal toxicity.5 Tinnitus does not occur. Blood urea nitrogen and serum creatinine determinations should be obtained every 3 or 4 months. In patients who do not obtain sufficient relief from acetaminophen, the dose can be reduced slightly and a small dose of propoxyphene added.
Most of the nonsteroidal antirheumatic drugs are also effective in reducing the pain and inflammation of osteoarthritis. However, especially in older persons, use of these drugs is frequently associated with gastropathy, often leading to upper gastrointestinal bleeding, which may be life-threatening.6,7 Unfortunately, screening for occult blood does not provide a warning of possible major blood loss; many patients in whom the Hemoccult test has been negative on several occasions suddenly develop an abrupt and unheralded upper gastrointestinal bleed. Similarly, one cannot count on upper gastrointestinal symptoms to provide a warning of an impending bleed.
The likelihood of nonsteroidal anti-inflammatory drug (NSAID) gastropathy can be reduced substantially if one seeks to identify and strictly avoid use of these drugs in patients at high risk for this complication. The risk factors include old age, multiple chronic diseases (such as heart disease, chronic obstructive pulmonary disease [COPD], and/or diabetes mellitus), and a history of a previous duodenal ulcer or upper gastrointestinal bleed.8 In the absence of these contraindications, use of these agents in a moderate dose, such as ibuprofen 400 mg three times a day, naproxen 375 mg twice daily (or, at most, 500 mg bid), or other NSAIDs in moderate doses taken with meals, carries a considerably reduced risk of upper gastrointestinal bleeding. In patients who are at high risk for gastropathy whose pain cannot be controlled by acetaminophen with, perhaps, small doses of propoxyphene added, one can consider several alternative approaches. While simultaneous administration of H2 blockers or sucralfate has little effect in inhibiting NSAID-induced gastric disease, misoprostol in a dose of 200 µg qid with meals and on retiring has been shown to be effective in this regard.9 Misoprostol also has a suppressive effect on NSAID-induced duodenal disease, but its effectiveness in this case is minimal and is no greater than that achieved by H2 blockers or sucralfate. Unfortunately, misoprostol is expensive and has a tendency to lead to diarrhea. Commencing therapy with a smaller dose, such as 100 µg two or three times daily, may alleviate this problem.
In patients in whom the symptoms are localized primarily in a single joint, intra-articular administration of a corticosteroid drug often yields relief that may last 3 or more months. These injections should not be repeated more frequently than three or four times a year, and the total series should not extend for more than a year and a half. In some patients administration of small doses of acetaminophen with codeine No. 3 may be indicated despite the risk of habituation. Surgical joint replacement may actually provide a better prognosis for life than use of NSAIDs in some of these high-risk patients with advanced osteoarthritis.
Exercise. A very important additional approach to providing symptomatic relief for patients with OA involves varied modalities of physical therapy, especially exercise.10 Several patterns of exercise have proved quite effective. One emphasizes active muscle contraction against resistance.11 For the quadriceps muscle, this can be accomplished by sitting on the edge of a firm table and raising the lower leg into the horizontal position using ankle weights. The weights, ranging between 1 and 7 pounds, are prescribed individually for each patient. We usually suggest 18 contractions, followed by a period in which the patient holds the knee horizontally extended for as long as possible; after a rest, the entire sequence is repeated over a period of 10 to 15 minutes. This process, which should be carried out within the limits of pain, should be repeated daily. Because exercises of this sort strengthen the muscle at the length at which the exercise is carried out, they should be performed with the patient in two positions, sitting vertically and lying horizontally with the lower legs dropped over the edge of the exercise table. An alternative approach, which is more difficult to monitor, is achieved by performing quadriceps setting exercises, in which the patient clenches the muscle vigorously but does not move the knee. This exercise should also be done in both sitting and lying positions. A 2 to 3 month exercise program, if conscientiously pursued, often results in significant increases in strength, decreased pain, and improvement in overall function. In our experience these benefits are particularly evident in patients who have experienced a crampy feeling in the legs after walking or at night.
The problem with a home-based exercise program is that it is extremely boring, and few patients will carry it out by themselves without frequent review and encouragement. Use of an exercise bicycle or rowing machine provides a more entertaining mode of exercise and is reasonably effective if it is carried out conscientiously. As an alternative, a group approach to exercise may be employed, with classes of approximately 20 patients supervised by a physical therapist and one assistant.12 Such a program should include patient education and social support. Results have shown significant benefits in relief of pain, increase in function, and enhancement of the patient’s sense of control over his or her disease.
An important aspect of management of patients with osteoarthritis is decreasing the level of stress on the joint as well as on the whole person. For individual patients, this may involve use of a cane or walker and, for obese people, loss of weight. Social and psychological support are also important elements of good care.13,14 Controlled trials have shown that programs of health education and continuing telephone contact with patients yield improved functional status and decreased overall costs.15,16 and 17
Surgery. Improved surgical intervention in patients with osteoarthritis, especially joint replacement, is one of the major advances that have occurred in rheumatology during the past 50 years. The attitude of the patient is an important determinant of success. A patient who is determined to regain full activity and does so quickly will achieve a far better result than the dependent “show me” type of person. Prior to surgery, the patient should be informed about the importance of appropriate follow-up, together with the need to receive prophylactic antibiotics in conjunction with dental and rectal procedures, which is similar to the recommendation for patients with artificial cardiac valves.
The second most frequent rheumatic disease among the older population is rheumatoid arthritis (RA). Despite the life-limiting impact of RA and its treatment,18,19 the majority of patients who develop the disease in early or midlife live on to old age and present to their physicians problems of reduced physical function, decreased resistance to infection, and, in many, severe osteoporosis secondary to long-term prednisone therapy. In addition, since the incidence of rheumatoid arthritis increases with age,20 a number of older patients with new-onset disease will be encountered as well.
The manifestations and course of RA in old people are slightly different from those in younger persons. Several clinical presentations have been described.21 Approximately one fourth of patients have an acute onset of disease, manifested by swelling, tenderness, and pain on motion of the hands, wrists, elbows, knees, and ankles. The disease occurs over the course of several days or even overnight and is often accompanied by severe morning stiffness and constitutional symptoms. Most of these patients experience a complete remission in time.22 In another group, possibly 25%, the pain, tenderness, and stiffness are focused primarily in the shoulders, hips, and wrists, sparing the hands. These patients have symptoms closely resembling those of polymyalgia rheumatica, including, in some, a markedly elevated ESR value, and their disease may bear a relationship to this disorder.23 Although, for the most part, patients with late-life onset have a somewhat better outcome in terms of the likelihood of remission than is true for patients with onset earlier in life, there is a small percentage of older patients who have a high titer of RF and have the same adverse course that prevails in younger persons with seropositive disease.
Differentiation of rheumatoid arthritis from osteoarthritis is extremely important and is often more difficult than it is in younger individuals. While the classic differential characteristics may be present in persons at midlife, this is frequently not the case in older patients. For example, osteoarthritis may involve the proximal interphalangeal joints more than the distal interphalangeal joints. Osteoarthritis of the large joints often leads to joint effusion and synovial thickening accompanied by warmth and sometimes tenderness, closely resembling the symptoms one sees in rheumatoid arthritis. While osteoarthritis does not lead to constitutional symptoms, older people frequently have coincidental diseases that can cause these symptoms. Many, possibly most, older patients experiencing new-onset RA have considerable osteoarthritis as well, which is enhanced in time by the sequelae of the rheumatoid process. The fact that both the ESR and RF values reach levels in many older people that would be significant in younger persons lessens the diagnostic value of these determinations in the older population. Thus, the differentiation between these common entities in many older people is by no means easy.
Synovial fluid examination often provides a reliable clue to the correct diagnosis. In patients with rheumatoid arthritis the fluid is watery in consistency, and the white cell count is almost always increased—in the range of 5000 to 25,000/mm3. In patients with osteoarthritis the fluid is viscous, and the white cell count is low. Synovial fluid should also be examined under polarized light for crystals of uric acid or calcium pyrophosphate. Calcium pyrophosphate deposition (CaPPD) disease often occurs in the presence of osteoarthritis and provides an additional explanation of the inflammatory manifestations that may be seen with this condition.24
The differential diagnosis between rheumatoid arthritis and osteoarthritis is important for therapy. Some patients with rheumatoid arthritis derive considerable relief from aspirin, coated or buffered, in a dose of 2.6 to 3.9 g/day (8 to 12 tablets) with meals. Use of higher doses, often recommended in younger persons, is rarely attempted in older people because of their increased sensitivity to the auditory and gastrointestinal side effects. Salsalate, 750 mg bid, provides a more convenient mode of administration of salicylate and has fewer gastrointestinal side effects. Determination of the blood salicylate level will confirm that the agent is in fact being absorbed. A concentration of 15 to 20 mg/dL is the desired level. In patients in whom salicylate provides inadequate relief, a trial with a NSAID is usually justified. The potential hazards of NSAID therapy and the precautions that should be taken have already been mentioned. Examples of commonly used NSAIDs include ibuprofen, 400 mg tid, sulindac (Clinoril) 150 mg bid, and naproxen 375 mg two or three times daily. Acetaminophen is seldom of value in patients with rheumatoid arthritis. It is rarely if ever justifiable to use codeine or other narcotic agents in patients with rheumatoid arthritis except in those in whom the symptoms focus in a single joint, such as the hip or knee, and a decision has already been made to undertake joint replacement. Joint injection with a corticosteroid preparation (usually given, for a large joint, in a dose of 40 mg of corticosteroid diluted in 3 to 4 mL of 1% lidocaine) almost always provides considerable symptomatic relief that may last for 2 to 4 months. These injections may be repeated two or three times during the course of a year. It is believed that larger series of injections exert an adverse effect on the articular tissues.
Simultaneously with the use of these agents, it is important to place the patient on a good conservative regimen, including rest and exercise. Rheumatoid arthritis is a constitutional disease, and carefully monitored rest is an important component of therapy. Rest should be prescribed in specific terms and with the same care one would take in prescribing a potentially toxic drug. As a rule, patients should achieve the degree of rest necessary to avoid fatigue. Complete bed rest, however, should never be prescribed for an older person for fear that the patient may lose the ability to walk. Even older patients with active arthritis should be encouraged to walk every day, often with the help of a walker, to the bathroom and meal table.
If an older patient fails to show symptomatic improvement during the course of about 6 to 8 weeks on this program, a more effective antirheumatic agent should be prescribed. Indeed, there is an increasing consensus that introduction of a second-line antirheumatic drug early in the course of the disease may attenuate the destructive changes of the disease.25 Although sulfasalazine and hydroxychloroquine have been extensively studied26 and have been shown to be valuable, especially in younger patients, their usefulness as sole second-line therapy in older patients remains questionable. As one describes the possibility that hydroxychloroquine may accumulate in their eyes and may affect the retina, many older patients become fearful and do not welcome the prospect of slit lamp and retinal examinations before and at intervals during therapy. A recently developed antirheumatic agent, tenidap, shows promise as an effective and relatively nontoxic alternative to NSAIDs,27 but little experience with it has yet been achieved in older patients.
In patients who do not respond to a 6- to 8-week trial of the conservative program outlined earlier, the addition of methotrexate, a folic acid antagonist, may offer additional benefit. To prevent secondary folic acid deficiency, patients receiving this drug should also be given folic acid, either 1 mg po qd or 5 mg 1 day per week. This does not interfere with the antirheumatic effectiveness of the methotrexate. Although severe pancytopenia has been described early in the course of methotrexate therapy,28 and guidelines clearly indicate the importance of obtaining complete blood cell counts at 1- to 2-month intervals throughout the course of treatment, this is a rare complication. The most common side effect, abnormalities in liver function, requires tests of the alanine aminotransferase (ALT) level at similar intervals. Since a decline in serum albumin concentration often precedes an elevation in the ALT level, it is a good practice to measure the serum ALT, serum albumin, and total protein (“liver profile”) as well as the complete blood cell count every 4 to 6 weeks. Alcohol should be strictly forbidden. The initial dose of methotrexate, 7.5 mg po 1 day per week, may be increased to twice that level if the initial response is not satisfactory.29 If gastrointestinal symptoms ensue, the drug may be given intramuscularly, watching the serum chemistry values and complete blood cell count carefully. Elevations of ALT to twice the upper levels of normal is not a cause for alarm, but higher values may require discontinuation of the drug. Since pulmonary fibrosis is an occasional but serious complication of methotrexate therapy, chest films should be obtained prior to initiation of treatment, at intervals of 1 to 1 ½ years afterwards, or if the patient develops chronic cough or dyspnea. The drug should be stopped immediately if pulmonary sequelae ensue.
Methotrexate is a highly effective agent in older people,30 especially in patients whose disease is accompanied by marked synovial thickening. Benefit is not achieved, however, until after about 2 months of treatment. If a satisfactory response is not obtained, even with an increased dosage, the addition of a second remittive drug, such as sulfasalazine or hydroxychloroquine, can be considered.31 In patients with seropositive rheumatoid arthritis, methotrexate therapy may be accompanied by an increase in the size of the nodules, an effect that may be attenuated by the addition of hydroxychloroquine. Once a satisfactory response has been achieved and the patient’s condition has stabilized, the dose should be tapered gradually, watching for signs of increased disease activity.
In patients in whom methotrexate, possibly in combination with another second-line agent, is not effective or is deemed inappropriate, and in patients in whom an immediate symptomatic improvement is mandated by their social situation or serious malnutrition and “failure to thrive,” the most practical alternative is low-dose prednisone therapy.32 Although the adverse implications of this approach, in terms of initiation or exacerbation of diabetes mellitus, hypertension, or osteoporosis, are not to be taken lightly, these sequelae are infrequently seen when doses are limited to not more than 8 mg/day (i.e., one 5-mg tablet and three 1-mg tablets, all taken together in the morning). It is prudent not to start therapy in patients with rheumatoid arthritis with doses greater than 10 mg/day. Reductions in dose should be undertaken extremely slowly. By restoring the capacity for enhanced physical activity to a patient who would otherwise be bed- or chair-bound, the benefits of the activity counterbalance to a considerable extent the negative effects of the drug on the osseous skeleton.
Osteoporosis constitutes an important threat for older patients with rheumatoid arthritis, especially those who are receiving maintenance prednisone therapy, even in low doses. Such patients should be given estrogen replacement therapy, if tolerated, and also supplemental calcium, with vitamin D, to yield a total intake of 1500 mg of calcium per day. Patients who are at high risk for osteoporosis, who cannot tolerate or will not accept estrogen replacement or in whom it is contraindicated, should receive alendronate, 10 mg per day, po, taken 45 minutes before breakfast, with the patient sitting erect.33 For patients with severe osteoporosis and fractures, a combination of estrogen and alendronate is probably indicated. Whether alendronate treatment should be continued for longer than 3 years has not yet been determined. Guidelines have recently been developed for prevention and management of steroid-induced osteoporosis in patients with rheumatoid arthritis.34
Continued treatment with methotrexate or prednisone or both does not relieve the patient from the need to continue all elements of the conservative program, including periods of rest, exercise (within the limits of pain), local heat or ice, as required by symptoms, and continued strides toward functional independence.
The frequency of gout increases with age, especially in postmenopausal women, in whom the frequency of acute attacks is equal to that of men of comparable age. Diagnosis is suspected on clinical grounds (which are slightly different in the older population)35 and is confirmed by the demonstration of urate crystals in synovial fluid. The treatment is more effective the earlier it is begun. Patients with recurrent gouty attacks can usually anticipate an attack by noting very minor symptoms. When these occur, prompt administration of 0.6 mg of colchicine, two or three tablets throughout the first day, followed by one tablet daily for 3 or 4 days, often aborts the attack. When full-blown gouty arthritis occurs, treatment with the classic regimen of colchicine (0.6 mg po every 2 hours until relief or diarrhea occurs) is not recommended in older patients. Short courses of a NSAID such as indomethacin, 100 mg the first day, 75 mg daily for 2 or 3 days, 50 mg for 2 or 3 days, 25 mg for 2 days, and then stop, are usually effective but may carry a high risk of gastropathy, as previously discussed. Prednisone in an initial dose of 20 mg/day is effective in some patients but disappointing in others. For gout in large joints, intra-articular injection of a corticosteroid may be effective and avoids the hazards of systemic therapy. It has recently been shown that a former mode of therapy, adrenocorticotropic hormone (ACTH), given in doses of 40 or 80 units intramuscularly three times a day with subsequent tapering over 3 or 4 days, is an effective mode of therapy in older patients with co-morbid disease.36 Colchicine, 0.6 mg/day, should be started at the midpoint of any of these regimens to decrease the likelihood of flare-up after the initial drug has been discontinued.
Patients with gout that has been inactive for a considerable period of time, either spontaneously or because of small doses of colchicine, may have an acute attack during periods of hospitalization for coincidental disease. It is important to anticipate and prevent this occurrence by continuing the colchicine or reestablishing it during the period of hospitalization. Gout is an eminently treatable condition. In managing an older patient with chronic or acute gout one should not be content with anything less than a perfect or close-to-perfect result.