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Allopurinol Uptitration — SCE Rheumatology MCQ

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EasyCrystal ArthropathyAllopurinol UptitrationSCE Rheumatology

A 55-year-old man with gout develops tophi on his ears and hands. Ultrasound of his feet shows double contour sign at both first MTP joints. His serum urate is 520 micromol/L despite Allopurinol 300 mg daily. What is the most appropriate next step?

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Correct answer: E — Increase Allopurinol dose (uptitrate monthly guided by serum urate) until the target of <300 micromol/L is achieved; doses up to 900 mg daily can be used if tolerated

This patient has not achieved the serum urate target (<300 micromol/L for tophaceous disease per BSR 2017). The most common reason for ULT failure is inadequate dose titration. Allopurinol should be uptitrated by 100 mg increments at monthly intervals guided by serum urate response. The maximum licensed dose is 900 mg daily (though doses above 300 mg are used less commonly). Many patients are maintained at 300 mg without checking whether target has been achieved (treat-to-target failure). If target is not achieved at maximum tolerated Allopurinol options include: switching to Febuxostat adding a uricosuric (if available) or considering Pegloticase for refractory tophaceous disease.

Reference: BSR 2017 gout; NICE NG219 (2022)