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Acute gout flare — MSRA MCQ

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ModerateAnkle and FootAcute gout flareMSRA

A 67-year-old man with crystal-proven gout presents with a 12-hour history of severe pain, erythema and swelling of the right first metatarsophalangeal joint. The presentation is identical to previous flares. He is afebrile and systemically well, with no skin break, recent procedure or features suggesting septic arthritis. He has CKD G3a (eGFR 52 mL/min/1.73 m²) and chronic heart failure treated with ramipril and furosemide. He is taking clarithromycin 500 mg twice daily for a lower respiratory tract infection, with 3 days of treatment remaining. He has no diabetes, active peptic ulcer disease or previous corticosteroid intolerance. What is the most appropriate treatment for this gout flare today?

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Correct answer: A — Prescribe a short course of oral prednisolone and advise adjunctive cold therapy

This is a clinically typical acute gout flare, without features requiring immediate assessment for septic arthritis. NICE recommends an NSAID, colchicine or a short course of oral corticosteroid as first-line treatment, selected according to comorbidities and co-prescriptions. Oral prednisolone is the best option here. NSAIDs are relatively unsuitable because he has CKD, heart failure and concurrent ramipril plus furosemide, which increase the risk of renal and fluid-related adverse effects. Colchicine is contraindicated because he has renal impairment and is concurrently taking clarithromycin, a strong CYP3A4 inhibitor; this combination can substantially increase colchicine exposure and toxicity. A proton-pump inhibitor reduces gastrointestinal risk from an NSAID but does not mitigate the renal or heart-failure risks. Intra-articular or intramuscular corticosteroid injection can be considered when NSAIDs and colchicine are contraindicated, not tolerated or ineffective, but a short oral corticosteroid course is an appropriate, accessible first-line treatment in this uncomplicated monoarticular flare. IL-1 inhibition is not routine primary-care treatment and requires rheumatology input after standard options are unsuitable or have failed. Ice packs may be advised alongside prescribed treatment.

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