Gout Treat-to-Target — RACP Adult Medicine MCQ

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EasyRheumatologyGout Treat-to-TargetRACP Adult Medicine

A 50-year-old man with longstanding gout on allopurinol 300 mg daily has a serum urate of 0.42 mmol/L (target <0.36 mmol/L). He has tophi on his elbows. What is the correct management?

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Correct answer: C — Increase allopurinol dose (e.g. to 400–600 mg daily)

The treat-to-target approach requires dose escalation of allopurinol until serum urate is <0.36 mmol/L (or <0.30 mmol/L in tophaceous gout). Allopurinol can be safely increased above 300 mg (up to 900 mg/day in some patients) with monitoring. Many patients are undertreated because doses are not up-titrated. In patients with tophi, a lower target (<0.30 mmol/L) promotes more rapid tophus resolution. Anti-inflammatory prophylaxis (colchicine 500 mcg daily) should continue during dose escalation.

Reference: eTG – 2025 – Rheumatology; ACR – 2020 – Gout Management Guideline