skip to main content

Acute gout flare affecting the ankle — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardAnkle and FootAcute gout flare affecting the ankleMSRA

A 72-year-old man presents with 14 hours of severe pain, warmth, erythema and swelling of his right ankle. He has had 3 previous crystal-proven gout flares affecting the first MTP joint. He is afebrile and systemically well; there is no skin break, recent procedure, spreading cellulitis or pain on passive movement beyond that expected from the swollen joint. His eGFR is 38 mL/min/1.73 m² and stable. He takes apixaban for atrial fibrillation and has a history of NSAID-associated upper gastrointestinal bleeding. He is on day 3 of a 7-day course of clarithromycin for a resolving dental infection. He is not taking urate-lowering therapy. What is the most appropriate pharmacological treatment for this gout flare today?

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

Reveal the answer and explanation

Correct answer: E — Prescribe a short course of oral prednisolone for the flare

This is a clinically characteristic recurrent gout flare involving the ankle. Septic arthritis must be considered in any hot swollen joint, but the established crystal-proven history and absence of systemic illness, portal of entry, spreading infection or concerning examination features make immediate septic arthritis referral less likely in this scenario. NICE recommends an NSAID, colchicine or a short course of oral corticosteroid as first-line flare treatment, selected according to comorbidities and co-prescriptions. Naproxen is inappropriate here because of CKD, apixaban use and previous NSAID-associated upper gastrointestinal bleeding. Colchicine is contraindicated: clarithromycin is a strong CYP3A4 inhibitor, and the colchicine SmPC contraindicates this combination in people with renal or hepatic impairment because of potentially fatal toxicity. A short oral corticosteroid course is therefore the best immediate option. Allopurinol lowers serum urate and may be considered subsequently as part of a treat-to-target long-term plan, but it does not provide adequate acute anti-inflammatory analgesia alone. Paracetamol and cold therapy may be adjuncts but are insufficient as sole treatment for this severe inflammatory flare.

Reference: NICE NG219: Gout: diagnosis and management — Recommendations (2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations NICE NG219: Gout: diagnosis and management (2025) — https://www.nice.org.uk/guidance/ng219/resources/gout-diagnosis-and-management-pdf-66143783599045 Colchicine 500 microgram tablets — Summary of Product Characteristics (June 2025) — https://www.medicines.org.uk/emc/product/100968/smpc