Which episodic management is safest for a patient with gout (one to four attacks per year)—indomethacin or colchicine? At what point do the benefits outweigh the risks of allopurinol (Zyloprim) for prophylaxis? My patient is a 55-year-old man in generally good health. He takes losartan (Cozaar) and lovastatin with good control of BP and LDL, respectively. His triglyceride levels remain in the high 200 mg/dL range.
—Christine R. Jones, RN, NP, Palm Desert, Calif.

Indomethacin may cause dizziness and headache and blunt BP control, while colchicine regularly causes cramping and diarrhea, often before gout resolves. Therefore, many patients prefer to take other nonsteroidal anti-inflammatory drugs or a short course of steroids (IM, p.o., or intra-articular). Risks associated with allopurinol occur very infrequently, and the benefits of this agent include prevention of attacks and future tophaceous growth, while limiting renal stone formation when uric acid is maintained below 6.0 mg/dL. Such control may require doses higher than the usual 300 mg/day.
—Jack Waxman, MD (99-4)