Cases/Musculoskeletal Health

Man Who Started Allopurinol and Now Has Another Gout Attack — Free SCA Practice Case

Man who started allopurinol and now has another gout attack

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

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Materials for Candidate

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Patient Profile

Full Name

Ranjit Sohal

Age

55 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day appointment requested by the patient.

Reason for Encounter

"My toe has flared up again and I'm worried about the new tablet."

Medical Records

●PMH: Gout, three attacks in 11 months (latest 8 weeks ago). BMI 31.
●Medications: Allopurinol 100 mg daily, started 3 weeks ago. Naproxen 500 mg with omeprazole for 7 days, issued 8 weeks ago.
●Allergies: NKDA.
●Social: School site manager. Non smoker.

Recent Notes

●Bloods before allopurinol: Urate 505, creatinine 92, eGFR 85, ALT 26. Repeat urate and kidney function due about 4 weeks after starting.

Patient Script

For the friend playing the patient role

Character Overview: You are Ranjit Sohal, a 55 year old site manager at a secondary school. You live with your wife Sunita and you are practical, a bit gruff and not one for tablets. You have had three attacks in your big toe joints over the past year and you started a daily tablet, allopurinol 100 mg, a little over three weeks ago to stop them. Two nights ago your right big toe flared again. You have decided the tablet is to blame, so you stopped taking it yesterday morning. You have read worrying things about it online. You are tired from two bad nights, but you are polite and will listen if the doctor takes your worry seriously. You call these episodes "attacks" or "my toe". You never use the medical name for the condition and you never say "uric acid".

Opening Sentence: "Hello Doctor. It's my toe again, the right one this time, and it's killing me. I've only been on that new tablet three weeks and I've had another attack, so I reckon it's the tablet doing it. I've stopped taking it."

History if Asked (Data Gathering Phase)

●This attack: "I woke up in the early hours, two nights ago, with the big toe on my right foot throbbing. By the morning it was red, swollen and so tender I couldn't have the duvet on it. It's about an eight out of ten. It's exactly the same as the other three times, hot and shiny."
●Earlier attacks: "The first was nearly a year ago, my left big toe. Then about five months ago it was the right one, and then the left again about eight weeks ago. So this is the fourth."
●The tablet: "Allopurinol, 100 milligrams, one every morning after breakfast. I never missed one until yesterday. I haven't taken any yesterday or today."
●Why he stopped: "Because the toe went off again three weeks after I started it. It seems obvious to me. It's the tablet."
●Anything to stop attacks coming, and blood tests (if asked): "No, they only gave me the one tablet. They told me to take it after food and that I'd have another blood test in about a month. Nothing since I started."
●What he has taken for this attack: "I put up with it the first day. Then I had some naproxen left over from last time. I took one yesterday evening and one this morning. It barely touched it, so in the night I took two ibuprofen as well. I didn't bother with the stomach tablet, I'm sick of tablets."
●Stomach, if asked: "Now you mention it, I've had a burning feeling in my chest since this morning, after the naproxen. A couple of indigestion tablets eased it. No black stools, I haven't been sick."
●Can he walk, if asked: "Only on my heel. I can't get my work boot on at all."

Ideas, Concerns, Expectations

Gating note: Ranjit does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He is convinced the tablet set the attack off. "I'd had a month with nothing and then I take that tablet and bang, three weeks later I'm in agony. It's got to be the tablet. Maybe my body just doesn't agree with it."
●Concerns: His biggest worry is what the tablet might be doing inside him. "I looked it up on a forum. People were saying it wrecks your kidneys and your liver, and others said it gave them more attacks. I don't want to be wrecking my insides for the sake of a toe." If the doctor explores further, he adds the practical worry: "And I'm on my feet walking the whole site all day, and I can't get my safety boot on. How am I supposed to do my job like this?"
●Expectations: He came hoping to be told to stay off it. "I was hoping you'd say forget that tablet and put me on something else, something gentler that doesn't do this. And something proper for the pain."

If Asked: Medical History and Medications

Gating note: Ranjit answers each of these plainly when the doctor asks about it.

●Other health problems: "Nothing really. I put a bit of weight on. Never had a stomach ulcer or bled. No kidney trouble or stones. No heart problems, my blood pressure's been fine, and I've never had asthma."
●Medicines: "Only the allopurinol. No water tablets, no aspirin, no blood thinners, no antibiotics for years, no supplements or herbal remedies. No allergies."
●Earlier treatment: "Naproxen worked last time and settled it in about four days. I took the stomach tablet with it and I was fine. I've never had colchicine or steroid tablets. No family history that I know of."

Social History and Lifestyle Impact

●Work: Ranjit is the site manager at a large secondary school. He walks the whole site and wears steel toe cap boots, and the school's rules say he cannot go round in trainers. "Yesterday I went in wearing trainers and did the minimum. Today I've phoned in sick. I hate letting the school down."
●Home: Lives with his wife Sunita. She is looking after him and is cross that he stopped the tablet without asking anyone.
●Drinks and food: "I get through two or three cans of cola a day, and tea with two sugars. I hardly drink water."
●Alcohol, weight and smoking: "A couple of whiskies on a Friday and Saturday night. I've put on about a stone and a half over the last few years. Never smoked."

If Asked: Associated Symptoms

●Fever, shivering, sweats, feeling unwell: "No, nothing like that. A bit tired, but I'm not ill."
●Injury, a cut, blister or break in the skin, redness spreading up the foot, other joints: "No. I haven't knocked it, the skin's all intact, the redness is only over the joint, and it's just the one toe."
●Reaction to the tablet (rash, itching, blisters, mouth sores, swelling of the lips or face, sore throat): "No rash, no itching, nothing in my mouth, no swelling and no sore throat."
●Lumps on the fingers, toes or elbows, dark urine, yellow eyes or back pain: "No lumps anywhere. No to all of that."
●If asked to look at, press or move the toe, take its temperature or send a photo: "I can't really touch it, it hurts too much even with a sock on. I can't send photos either. If you want someone to look at it, I'll come in."

Responses to Management (The Negotiation Phase)

●
If the doctor says attacks are expected in the first months of this tablet, or advises restarting it today or once the attack has eased:
- ●Reaction: Sceptical at first, then curious. "Hang on, how can that be? I'd had about a month with nothing." If told in plain words that the tablet is clearing crystals stored in the joints and this can stir things up: "Right. So it's shifting what's already in there. I can understand that." On restarting: "Today? And if I get another attack next month, you'll tell me to carry on again?" He agrees once he has a reason and a plan. If told to wait until the toe is better: "How will I know when?" If the doctor agrees he should stay off it without a reason, relieved: "That's what I was hoping you'd say."
●
If the doctor asks about or advises naproxen, ibuprofen or another anti inflammatory painkiller, or offers colchicine or a short course of steroids:
- ●Reaction: Puzzled if he has not been asked what he has taken: "I've actually had some of those already. Should I carry on with all of them?" If told not to take two together: "I didn't think that mattered." If an anti inflammatory is advised without stomach protection: "I did get that burning in my chest this morning. Is that going to be a problem?" On colchicine: "What does it do to your stomach? How quickly would it work?" He accepts once he hears about possible diarrhoea. On steroids: "Won't that put weight on me?" He accepts if told it is only a few days.
●
If the doctor offers a tablet to prevent attacks while the dose is built up, or explains that the dose will go up in steps:
- ●Reaction: Wary. "Another tablet on top? That's what I'm fed up with. How long would I be on that one?" If it is explained as covering the first months and he is given the choice: "If it keeps these attacks off while the other one settles, I'll give it a go. It is up to me, isn't it?" If he feels pushed, he refuses. On dose steps: "Won't that make it worse?" He accepts when told it is gradual and checked by blood tests.
●
If the doctor reassures him about his kidneys and liver, or says the treatment is usually long term:
- ●Reaction: If reassured in general terms only: "People online said different." If given specifics about his own kidney and liver tests, to be checked again: "Right, so you looked at mine before I started? That's more than I read." On long term: "Years of it? Is it worth it?" He settles if told attacks may still come in the early months but should become fewer.
●
If the doctor raises cola, alcohol, water or weight, offers to see him in person, or asks about work or a fit note:
- ●Reaction: On lifestyle, honest but defensive: "I do live on cola and tea. I can cut down, but I'm not giving up everything. Will that actually make a difference?" He is more receptive if told changes help but do not replace the tablet. On being seen: "Yes please. Sunita will have to bring me." On work: "Do I need a note off you, or can I just tell the head?"
●
If the doctor gives vague safety netting, such as "come back if it gets worse":
- ●Reaction: "Worse how? It's already bad. What exactly should I look out for, and who do I ring in the night?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Ranjit has gout with four attacks in 11 months. His serum urate was 505 micromol/L when he started allopurinol 100 mg daily, and three weeks later his right big toe flared and he stopped it. The skill is recognising an expected attack during initiation of urate lowering therapy (ULT), keeping the allopurinol going, treating the attack, offering cover against more attacks and setting up a treat to target plan.
●The BNF says starting or increasing allopurinol may precipitate an acute attack, that it is not a treatment for an acute attack, and that it should be continued if an attack develops, with the attack treated separately. NICE NG219 (June 2022) notes flares may increase in the first year of treat to target and fall by the second once the dose is stable.
●Model plan: a focused history including what he has taken, screening for infection and for a reaction to allopurinol, advising restart today and explaining why, one first line treatment for the attack, stopping the two NSAIDs being taken together, colchicine or other cover while the dose is built up, a target urate below 360 micromol/L with monthly blood tests and 100 mg steps, the urate and kidney function now due, specific safety netting, and answering his kidney and liver fear with his own normal results.
●Acceptable alternatives: restarting within a few days as the attack settles with a definite plan (a named day or once the pain has eased), since guidance says to continue allopurinol during an attack but does not address a short break; telephone management with follow up, or a face to face assessment today; raising the dose after the next blood result rather than today. What does not pass is leaving him off it, or swapping the drug because of the attack alone.

Why Not to Stop the Tablet

●NICE Clinical Knowledge Summaries (CKS) advise people who have attacks after starting allopurinol to continue it, treat each attack as soon as it occurs and be reassured that continuous treatment will reduce future attacks. Serum urate can rise quickly once ULT is stopped (NG219).
●An attack on starting treatment is not an adverse reaction. Genuine reasons to stop are a rash or hypersensitivity (section 7), or intolerance, when NG219 allows a switch to febuxostat. Any ULT can set off an attack, so switching drug does not solve the problem.

Assessing a Hot Joint by Telephone

●Infection cannot be excluded by phone. CKS says to refer immediately, according to the local pathway, if septic arthritis is suspected.
●Features supporting a typical attack: the same joint pattern, onset over hours, no fever or illness, no injury or broken skin, no other joint involved. Fever or shivering, feeling unwell, spreading redness, an atypical pattern or no improvement should move the plan to same day face to face or hospital assessment. CKS advises return if worse or no improvement after 1 to 2 days of treatment.

Treating the Attack and the Safety of What He Has Taken

●NG219 recommends an NSAID, colchicine or a short course of oral corticosteroid as first line, taking comorbidities, co prescriptions and preferences into account, started as soon as possible. Ice packs may help, with rest, elevation and paracetamol as adjuncts. Aspirin is not indicated.
●NSAID: maximum dose until 1 to 2 days after the attack resolves, with a PPI considered (BNF naproxen for acute gout is 750 mg once, then 250 mg every 8 hours). Colchicine: 500 micrograms 2 to 4 times a day until symptoms ease, no more than 6 mg in a course, not repeated within 3 days. Prednisolone 30 to 35 mg once daily for 3 to 5 days (CKS, off label). A joint injection is for when the others are unsuitable.
●Ranjit has no ulcer history, normal kidney function (eGFR 85), no interacting medicines and tolerated naproxen with omeprazole before, so all three routes are acceptable. After heartburn on two NSAIDs without stomach protection, colchicine is easiest to justify, though an NSAID with a PPI is supported.
●The BNF advises against more than one oral NSAID at a time, and lists dehydration as a caution for NSAIDs because of kidney risk. He has taken naproxen and ibuprofen together and drinks little water, so asking what he has taken is the key question.
●Colchicine has a narrow therapeutic window. Macrolide antibiotics, ritonavir, verapamil and ciclosporin raise levels, with reduced dosing if eGFR is 10 to 50 and contraindication below 10. Ranjit takes nothing that interacts. Tell him to stop it and ring for severe diarrhoea or vomiting.

Preventing Attacks While the Dose Is Built Up

●NG219: discuss the benefits and risks of preventing attacks when starting or increasing ULT, offer colchicine to people who choose it while the target is being reached, and consider a low dose NSAID or low dose corticosteroid if colchicine is unsuitable, with a PPI considered. The BNF colchicine dose for this is 500 micrograms twice daily.
●NG219 gives no fixed duration. CKS quotes the British Society for Rheumatology as up to 6 months. No cover was prescribed when he started allopurinol, and the candidate can say so without blaming anyone. If he declines after a proper discussion, that is his choice and the task is done.

Treat to Target Titration

●NG219: start low, use monthly serum urate to guide increases until below 360 micromol/L, considering below 300 if he has tophi, chronic gouty arthritis or frequent attacks despite a level below 360. CKS: allopurinol 100 mg or less daily after food, adjusted in 100 mg steps every 4 weeks, with kidney function checked alongside the urate.
●Dividing doses above 300 mg reduces stomach upset, and fluid intake of 2 to 3 litres a day is advised (BNF).
●His repeat urate is due about 4 weeks after starting. ULT is usually lifelong once on target. Switch to febuxostat if the target is not reached or allopurinol is not tolerated.

Allopurinol Safety: A Real Reason to Stop

●A rash should prompt stopping allopurinol immediately and seeking advice (CKS). If mild it may be cautiously reintroduced (BNF), but if a severe cutaneous reaction such as Stevens Johnson syndrome or hypersensitivity cannot be ruled out it should not be reintroduced. Allopurinol is avoided in people known to carry HLA B*5801, and azathioprine needs its dose cut to a quarter.
●Ranjit has no rash, mouth sores, fever, facial swelling or sore throat, so there is no reason to stop, but the safety net should say which signs would change that.
●His kidney and liver fear is best answered with his own results: creatinine 92, eGFR 85 and ALT 26 before he started, with kidney function rechecked alongside the urate.

Lifestyle, Follow Up and Referral

●NG219: not enough evidence that any specific diet prevents attacks, advise a healthy balanced diet, and excess weight and alcohol may worsen attacks. CKS adds that the BSR advises avoiding sugar sweetened drinks. Ranjit has cola, little water and weekend whisky, so negotiate changes he can manage without a lecture.
●NG219 suggests follow up after an attack settles (CKS: 4 to 6 weeks) to measure urate and review cardiovascular risk, CKD and medicines.
●Consider rheumatology referral if the diagnosis is uncertain, treatment is contraindicated, not tolerated or ineffective, in CKD stages 3b to 5, or after organ transplant, and CKS suggests specialist advice for gout under 30, in pregnancy, or with a suspected systemic illness. None applies to Ranjit now.

Talking With a Man Who Blames the Tablet

●Acknowledge that the timing looks like the tablet, then explain simply that it is clearing crystals. Answer the kidney and liver fear with his own results, without promising there is no risk.
●He is fed up with tablets, so explain why each is needed and for how long, and leave the choice of the extra preventive tablet with him. Be honest that treatment is long term and attacks may still come in the first year.
●Ask about work. He cannot get his boot on, and he can self certify for up to 7 days, needing a fit note only if off for longer.

Common Mistakes in This Station

●Agreeing that the tablet caused the attack and leaving him off it, or switching drug because of the attack alone.
●Treating the attack and never mentioning the allopurinol again.
●Not asking what he has already taken, so naproxen and ibuprofen together and the heartburn are missed.
●Advising an NSAID without a PPI after he has described heartburn, or leaving him on two NSAIDs.
●No mention of medicines to prevent attacks in the first months, or offering them with no end point.
●No target serum urate, blood test plan or 100 mg step plan.
●Telling him that diet or weight loss alone will control it.
●Not asking about rash, and giving no specific safety net for infection or reaction.
●Blanket reassurance about his kidneys and liver instead of his own results, and passing over the effect on his job.

Mapped to the RCGP curriculum topic: Musculoskeletal Health.

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