Gout-Initiating ULT — ABIM Board MCQ
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Correct answer: B — Start allopurinol 100 mg daily and titrate based on serum urate to target <6 mg/dL
Option B is correct. The 2020 ACR guidelines strongly recommend allopurinol as first-line urate-lowering therapy for patients with recurrent gout flares, with low-dose initiation (≤100 mg/day) and titration to a serum urate target <6 mg/dL. This patient has clear indication (≥3 flares/year) and is being treated between flares, the ideal time to initiate ULT. Option A: probenecid is second-line and not preferred for initial therapy. Option C: colchicine alone does not address the underlying hyperuricemia and is used as prophylaxis alongside ULT, not instead of it. Option D: HLA-B*5801 testing is not indicated for febuxostat use and is most relevant for assessing allopurinol hypersensitivity risk in high-risk populations; moreover, febuxostat is second-line after allopurinol. Option E: delaying therapy until tophi develop is inappropriate and allows preventable disease progression.
Reference: American College of Rheumatology. 2020 Guideline for the Management of Gout. Ann Rheum Dis. 2020 [https://pmc.ncbi.nlm.nih.gov/articles/PMC10563586/]