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Acute gout — MCCQE Part 1 MCQ

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ModerateJoint PainAcute goutMCCQE Part 1

A 68-year-old man with eGFR 35 mL/min/1.73 m² develops an acute gout flare in the first metatarsophalangeal joint. Synovial fluid shows monosodium urate crystals and a negative Gram stain. He is completing clarithromycin for pneumonia and is not taking chronic urate-lowering therapy. Which option is the safest appropriate treatment for this flare?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — A short course of an oral glucocorticoid such as prednisone

A short oral glucocorticoid course is an accepted first-line treatment for a gout flare and is the safest option listed in this patient. NSAIDs such as high-dose indomethacin can worsen kidney function and cause gastrointestinal and cardiovascular harm in an older adult with CKD. Clarithromycin strongly inhibits CYP3A4 and can markedly increase colchicine exposure; Canadian product information warns that colchicine and clarithromycin should not be used together in older people or those with renal impairment because fatal toxicity has occurred. Allopurinol and probenecid are urate-lowering drugs, not sole treatments for the acute inflammation. The long-term indication and starting dose for urate-lowering therapy should be assessed separately after the immediate flare plan is safe.

Reference: American College of Rheumatology, 2020 Guideline for the Management of Gout, https://rheumatology.org/gout-guideline; Health Canada-hosted clarithromycin product monograph, https://pdf.hres.ca/dpd_pm/00017875.PDF