Gout — SCE Rheumatology MCQ

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HardCrystal ArthropathyGoutSCE Rheumatology

A 65-year-old man presents with acute monoarthritis of the right knee. He has CKD stage 4 and takes Ciclosporin for a renal transplant. Joint aspiration shows MSU crystals. His serum urate is 620 micromol/L. Which urate-lowering therapy is preferred in transplant patients on Ciclosporin?

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Correct answer: A — Allopurinol starting at 50 mg daily

In transplant patients on Ciclosporin, Allopurinol is the preferred ULT, starting at a low dose (50 mg in CKD stage 4) and titrating cautiously. Febuxostat can be used if Allopurinol is not tolerated. Uricosuric agents (Probenecid, Benzbromarone, Lesinurad) are generally ineffective in advanced CKD and may interact with immunosuppressants. Importantly, Azathioprine is contraindicated with Allopurinol due to the drug interaction, but transplant patients on Ciclosporin/Tacrolimus do not have this issue. Dose adjustment based on renal function is essential.

Reference: BSR 2017 gout guidelines; NICE CG182 CKD; BNF Allopurinol in renal impairment