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Diabetic kidney disease — USMLE Step 2 CK MCQ

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EasyInternal MedicineDiabetic kidney diseaseUSMLE Step 2 CK

A 63-year-old man with stage 3 chronic kidney disease has had four crystal-proven gout flares during the past year and has a small tophus on the right first toe. He is currently between flares. Serum urate is 9.6 mg/dL. He has no previous allopurinol exposure or known severe drug reaction. Which long-term strategy is most appropriate?

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Correct answer: B — Start low-dose allopurinol, titrate to a serum-urate target, and give temporary flare prophylaxis

Frequent flares and a tophus are strong indications for long-term urate-lowering therapy. Allopurinol is preferred first line even in stage 3 or worse CKD. It should begin at a low dose, generally no more than 100 mg daily and lower in CKD when appropriate, then be titrated using serial serum urate measurements toward a target below 6 mg/dL. Colchicine, an NSAID, or a glucocorticoid is given as prophylaxis for at least the early months because starting urate-lowering therapy can precipitate flares. Starting at a very high allopurinol dose increases toxicity risk and worsens early flare risk. Probenecid is less suitable with reduced kidney function. Febuxostat is an alternative in selected patients but should not be started at maximum dose without titration. The absence of an active flare does not remove the indication for prevention.

Reference: American College of Rheumatology. Guideline for the Management of Gout. https://rheumatology.org/gout-guideline