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Acute gout flare — SCE Rheumatology MCQ

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ModeratePain ManagementAcute gout flareSCE Rheumatology

A 76-year-old man with recurrent gout presents with 36 hours of severe pain and swelling affecting both ankles and the right knee. He is unable to weight-bear. Aspiration of the knee identifies abundant intracellular monosodium urate crystals; Gram stain is negative and synovial fluid culture remains negative after 48 hours. He is afebrile and systemically well. His comorbidities include chronic kidney disease G3b (eGFR 34 mL/min/1.73 m²), heart failure with preserved ejection fraction and atrial fibrillation. Regular medication includes apixaban and modified-release verapamil. He has no diabetes, active infection or previous glucocorticoid intolerance. Which anti-inflammatory treatment is most appropriate for this gout flare?

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

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Correct answer: C — Start a short course of oral prednisolone

NICE recommends an NSAID, colchicine or a short course of oral corticosteroid as first-line treatment for a gout flare, with selection determined by comorbidities and co-prescriptions. Oral prednisolone is the best option here because the flare is polyarticular and there is no stated contraindication to short-course systemic glucocorticoid treatment. Naproxen is unattractive because CKD, heart failure and concomitant apixaban collectively increase renal, fluid-retention and bleeding concerns. Colchicine is not appropriate: the UK product information contraindicates colchicine in patients with renal impairment who are taking a P-glycoprotein inhibitor such as verapamil because exposure and potentially fatal toxicity may increase. Intra-articular triamcinolone could treat the aspirated knee but would leave both symptomatic ankles untreated. It would be a reasonable option for a predominantly monoarticular flare when injection is feasible. Anakinra can be effective in refractory gout, but NICE advises against an IL-1 inhibitor unless NSAIDs, colchicine and corticosteroids are contraindicated, not tolerated or ineffective, with rheumatology involvement before prescribing. This patient has not yet received an appropriate corticosteroid course, so escalation to an IL-1 inhibitor is premature.

Reference: Gout: diagnosis and management (NG219) — Recommendations (Published 9 June 2022; checked 19 August 2026) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations Colchicine 500 microgram tablets — Summary of Product Characteristics (Updated 12 June 2025) — https://www.medicines.org.uk/emc/product/100968/smpc Apixaban 2.5 mg film-coated tablets — Summary of Product Characteristics (Updated 11 August 2026) — https://www.medicines.org.uk/emc/product/100228/smpc