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Acute gout flare in chronic kidney disease with a colchicine–verapamil interaction — SCE Rheumatology MCQ

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ModerateColchicineAcute gout flare in chronic kidney disease with a colchicine–verapamil interactionSCE Rheumatology

A 68-year-old man with crystal-proven gout presents with a 36-hour flare affecting his right knee and both ankles. Knee aspirate contains intracellular monosodium urate crystals; Gram stain is negative and culture shows no growth at 48 hours. He has chronic kidney disease with a stable eGFR of 43 mL/min/1.73 m², atrial fibrillation treated with apixaban and verapamil MR, and a previous NSAID-associated upper gastrointestinal bleed. His type 2 diabetes is controlled with metformin (HbA1c 52 mmol/mol). He has no evidence of active infection. Which is the most appropriate pharmacological treatment for this flare?

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Correct answer: E — Commence a short course of oral prednisolone

A short course of oral prednisolone is the best treatment because both colchicine and an NSAID are unsuitable in this patient. Verapamil inhibits P-glycoprotein and CYP3A4. The colchicine SmPC contraindicates colchicine in patients with renal impairment who are taking a P-glycoprotein inhibitor because substantially increased exposure can cause serious or fatal toxicity. Merely reducing the colchicine dose does not override this contraindication. Naproxen is a poor choice given CKD, concurrent apixaban and a previous NSAID-associated gastrointestinal bleed; a proton-pump inhibitor would not remove the renal or systemic bleeding risks. Although corticosteroids may transiently worsen glycaemia, controlled diabetes is not a contraindication, and the polyarticular distribution makes systemic treatment appropriate. An IL-1 inhibitor is premature. NICE advises that IL-1 inhibition should not be offered for a gout flare unless NSAIDs, colchicine and corticosteroids are all contraindicated, not tolerated or ineffective, with rheumatology involvement before prescribing. Here, corticosteroid treatment remains available and appropriate.

Reference: Colchicine 500 microgram tablets — Summary of Product Characteristics (Text revised 1 December 2023; emc page updated 12 June 2025) — https://www.medicines.org.uk/emc/product/100968/smpc NICE NG219: Gout — diagnosis and management, recommendations (9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations