skip to main content

Gout — MSRA MCQ

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

HardAnkle and FootGoutMSRA

A 68-year-old woman attends for review 3 weeks after a crystal-proven gout flare affecting the left first metatarsophalangeal joint. The flare has fully resolved. She has had 3 similarly troublesome flares in the past year and her serum urate is 510 micromol/L. She has CKD G3a (eGFR 48 mL/min/1.73 m²), a previous NSTEMI, and takes apixaban and lansoprazole. She is completing a 7-day course of clarithromycin for a culture-directed respiratory infection, with 4 days remaining. There is no active joint inflammation, tophi, fever or diagnostic uncertainty. What is the most appropriate long-term gout management today?

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

Reveal the answer and explanation

Correct answer: B — Start allopurinol 100 mg daily with low-dose oral corticosteroid prophylaxis, then titrate allopurinol against monthly serum urate measurements to a target below 360 micromol/L

She should be offered urate-lowering therapy (ULT): she has multiple troublesome flares and CKD G3a. Her flare settled 3 weeks ago, which is within NICE’s recommended 2- to 4-week interval for starting ULT after a flare. Allopurinol is preferred over febuxostat because she has established major cardiovascular disease (previous NSTEMI). It should be started at a low dose and titrated using monthly serum urate concentrations to a target below 360 micromol/L. Flare prophylaxis should be discussed when ULT is initiated. Colchicine would usually be first choice, but it is contraindicated here because she has renal impairment and is taking clarithromycin, a strong CYP3A4/P-glycoprotein inhibitor. NSAID prophylaxis is unattractive given CKD, apixaban and previous gastrointestinal risk; low-dose oral corticosteroid prophylaxis is therefore the appropriate alternative. B uses the less appropriate first-line ULT in established cardiovascular disease and includes contraindicated colchicine. C and E inappropriately withhold indicated preventive treatment. D uses an unnecessarily high starting dose, omits prophylaxis and does not use treat-to-target monitoring.

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 Allopurinol Tablets BP 100 mg — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/14283/smpc