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Recurrent gout — SCE Rheumatology MCQ

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ModerateCrystal arthropathiesRecurrent goutSCE Rheumatology

A 49-year-old man with crystal-proven gout is reviewed 3 weeks after his latest flare completely settled. He has experienced three flares in the past year, and his serum urate is 560 micromol/L. Renal and liver function are normal. What is the most appropriate long-term management?

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Correct answer: E — Start low-dose allopurinol with treat-to-target titration and discuss colchicine prophylaxis

The correct answer is E. Three flares within a year constitute multiple gout flares and are an indication for long-term urate-lowering therapy. NICE recommends a treat-to-target strategy: begin urate-lowering therapy at a low dose, check serum urate monthly and titrate until it is below 360 micromol/L. Allopurinol is an appropriate first-line choice here. The benefits and risks of flare prophylaxis should be discussed, with colchicine offered during titration if chosen. Lifestyle measures alone or colchicine used only for acute flares will not eliminate the urate crystal burden. Scheduled intra-articular corticosteroids are not preventive therapy. Febuxostat is also a possible first-line urate-lowering drug, but it should not be initiated at the maximum dose without titration.

Reference: National Institute for Health and Care Excellence. NG219, Gout: diagnosis and management, recommendations 1.5.1 and 1.5.4–1.5.12. 2022. https://www.nice.org.uk/guidance/ng219/chapter/Recommendations