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Recurrent gout — MSRA MCQ

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HardAnkle and FootRecurrent goutMSRA

A 68-year-old man attends 3 weeks after complete resolution of his third crystal-proven podagra flare in 12 months. He has CKD G3b (eGFR 38 mL/min/1.73 m²), previous NSTEMI and hypertension treated with ramipril and indapamide. His serum urate is 518 micromol/L. He has no tophi, is not currently taking colchicine, and has no history of colchicine intolerance. He asks how to prevent further attacks. What is the most appropriate long-term pharmacological management today?

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

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Correct answer: A — Start low-dose allopurinol with colchicine prophylaxis, then titrate using monthly serum urate measurements to a target below 360 micromol/L

Explanation lettering: D = shown as A · A = shown as B · E = shown as C · C = shown as D · B = shown as E

This man has recurrent gout and CKD G3b, both indications to offer urate-lowering therapy (ULT). His flare settled 3 weeks ago, which is within NICE's preferred window of starting ULT at least 2 to 4 weeks after flare resolution. His previous NSTEMI is the key treatment discriminator: NICE recommends allopurinol, rather than febuxostat, as first-line ULT in people with major cardiovascular disease. ULT should be started at a low dose, with dose escalation guided by monthly serum urate measurements until the usual target of less than 360 micromol/L is achieved. Colchicine should be offered as flare prophylaxis while the target is being reached; dose adjustment or interval extension is needed in renal impairment. A is wrong because lifestyle advice is adjunctive and does not replace indicated ULT. B selects an unnecessarily low target in the absence of tophi, chronic gouty arthritis or persistent frequent flares despite urate below 360 micromol/L; febuxostat is also not preferred with major cardiovascular disease. C uses an inappropriately high starting dose, omits prophylaxis and delays monitoring. E is plausible because NICE advises considering rheumatology referral in CKD G3b to G5, but this does not require withholding appropriate first-line ULT in primary care when the diagnosis is established and treatment is feasible.

Reference: NICE NG219: Gout: diagnosis and management — Recommendations (2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations Allopurinol Tablets BP 100 mg — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/14283/smpc Colchicine 500 microgram tablets — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/100968/smpc