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Gout prevention — ABIM Board MCQ

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ModerateRheumatology/Allergy/ImmunologyGout preventionABIM Board

A 60-year-old man has had three crystal-proven gout flares during the past year and has subcutaneous tophi on both ears. His serum urate level is 9.8 mg/dL, and his eGFR is 58 mL/min/1.73 m². He is not currently having a flare and has no contraindication to allopurinol or colchicine. Which of the following is the most appropriate long-term management?

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Correct answer: E — Initiate low-dose allopurinol, titrate to a serum urate below 6 mg/dL, and provide colchicine prophylaxis for 3–6 months

The correct answer is E. Both subcutaneous tophi and frequent flares (at least two annually) are strong indications for long-term urate-lowering therapy. Allopurinol remains the preferred first-line agent in chronic kidney disease; reduced kidney function requires a low starting dose and careful upward titration rather than avoidance. Treatment should follow a treat-to-target strategy with serial serum urate measurements and a goal below 6 mg/dL. Colchicine or another appropriate anti-inflammatory prophylactic agent should generally be continued for 3–6 months because initiating urate-lowering therapy can precipitate flares. Starting allopurinol at 300 mg is unnecessarily aggressive. Probenecid is not preferred over a xanthine oxidase inhibitor in CKD. Treating flares alone permits ongoing crystal deposition and joint damage. Febuxostat is an alternative when allopurinol is unsuitable, but it should also be started at a low dose with flare prophylaxis.

Reference: FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research. 2020. https://pubmed.ncbi.nlm.nih.gov/32391934/