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Gout — SCE Rheumatology MCQ

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ModerateFlare ProphylaxisGoutSCE Rheumatology

A 76-year-old man with recurrent crystal-proven gout is commencing allopurinol using monthly serum urate-guided dose titration. His most recent flare settled 3 weeks ago. He understands that starting urate-lowering therapy may precipitate further flares and wishes to take pharmacological prophylaxis. His eGFR is 38 mL/min/1.73 m². He takes verapamil and apixaban for atrial fibrillation. Four years ago, he required endoscopic treatment for a bleeding duodenal ulcer. He has no diabetes, active infection, osteoporosis or previous adverse reaction to corticosteroids. Which is the most appropriate flare-prophylaxis strategy while his target serum urate level is being reached?

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Correct answer: B — Low-dose oral corticosteroid with proton-pump inhibitor gastroprotection

NICE recommends colchicine first-line for patients choosing flare prophylaxis during initiation or titration of urate-lowering therapy, with a low-dose NSAID or low-dose oral corticosteroid considered when colchicine is contraindicated, not tolerated or ineffective. Here, colchicine is contraindicated rather than merely requiring dose reduction: the UK SmPC contraindicates its use in patients with renal impairment who are taking a P-glycoprotein inhibitor, explicitly including verapamil. Naproxen is a poor alternative because of CKD, concurrent anticoagulation and previous ulcer bleeding; a proton-pump inhibitor would not eliminate its renal or haemorrhagic risks. Low-dose oral corticosteroid is therefore the best available conventional prophylaxis. His previous complicated ulcer and anticoagulation provide strong reasons to add gastroprotection. An IL-1 inhibitor is reserved for situations in which colchicine, NSAIDs and corticosteroids are all contraindicated, not tolerated or ineffective, which is not the case here. Pharmacological prophylaxis is preference-sensitive, so no prophylaxis could be reasonable if he declined it; however, he specifically wishes to receive prophylaxis and has a suitable NICE-supported option.

Reference: Gout: diagnosis and management — Recommendations (9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations Colchicine 500 microgram tablets — Summary of Product Characteristics (12 June 2025) — https://www.medicines.org.uk/emc/product/100968/smpc