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Chronic tophaceous gout — SCE Rheumatology MCQ

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ModerateUrate-Lowering TherapyChronic tophaceous goutSCE Rheumatology

A 59-year-old man has crystal-proven gout with bulky digital and olecranon tophi that impair hand function. Over 18 months, allopurinol has been increased at monthly intervals to his maximum tolerated dose. Adherence is confirmed, and his three most recent serum urate concentrations have been 332–346 micromol/L. He has had no gout flare for 10 months, but the tophi have not regressed. His eGFR is 72 mL/min/1.73 m², and he has no history of myocardial infarction, stroke or unstable angina. Which urate-lowering strategy is most appropriate?

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

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Correct answer: A — Switch to febuxostat monotherapy, adopting a target below 300 micromol/L

Explanation lettering: B = shown as A · A = shown as B

The persistent, functionally significant tophi are the key discriminator. Although this patient's serum urate is below the general target of 360 micromol/L, NICE advises considering a lower target below 300 micromol/L in people with tophi or chronic gouty arthritis. His lack of recent flares does not remove the need to eliminate the urate crystal burden. Allopurinol has already been titrated using serial urate measurements to the maximum dose he can tolerate, yet the clinically appropriate lower target has not been reached. NICE therefore supports switching to the alternative xanthine oxidase inhibitor, febuxostat. The absence of major cardiovascular disease removes the specific NICE preference for allopurinol as first-line treatment in that population. A accepts the general target despite persistent tophaceous disease. C is incorrect because colchicine prevents inflammatory flares but does not lower serum urate or dissolve tophi. D uses two xanthine oxidase inhibitors together; NICE recommends switching between allopurinol and febuxostat rather than combining them. E correctly identifies the need to change drug but retains an insufficiently stringent target for this patient's substantial tophus burden.

Reference: Gout: diagnosis and management (NG219) — Recommendations (Published 9 June 2022; last reviewed 9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations