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Refractory Tophaceous Gout — RACP Adult Medicine MCQ

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ModerateRheumatologyRefractory Tophaceous GoutRACP Adult Medicine

A 60-year-old man with longstanding gout (tophi on elbows and ears) has a serum urate of 0.58 mmol/L on allopurinol 900 mg daily. He continues to have frequent gout flares despite maximum tolerated allopurinol. eGFR is 35 mL/min/1.73m². What is the most appropriate next step?

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Correct answer: A — Switch to febuxostat

Persistent hyperuricaemia and flares despite maximum allopurinol warrants switching to febuxostat (an alternative xanthine oxidase inhibitor). Febuxostat 80–120 mg daily may achieve urate targets when allopurinol fails. It is not renally cleared, making it useful in CKD (though cardiovascular safety requires monitoring per CARES trial). Target urate is <0.36 mmol/L (<0.30 for tophaceous gout).

Reference: ARA – 2024 – Gout Guidelines; EULAR 2024 Gout; eTG Rheumatology 2024