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Tophaceous gout — SCE Rheumatology MCQ

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ModerateSerum UrateTophaceous goutSCE Rheumatology

A 62-year-old man has crystal-proven gout with firm tophi over the right second toe and left ear helix. His history includes a non-ST-elevation myocardial infarction 4 years ago and chronic kidney disease G3a, with an estimated glomerular filtration rate of 52 mL/min/1.73 m². Allopurinol was commenced at 100 mg daily and increased to 200 mg daily after 1 month. Serum urate was 528 micromol/L before treatment, 382 micromol/L after 1 month and 324 micromol/L after 2 months. Adherence is confirmed. He has developed no rash or other adverse effects, and his liver function tests are normal. Which urate-lowering strategy is most appropriate now?

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

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Correct answer: A — Up-titrate allopurinol as tolerated and repeat serum urate monthly, using a target below 300 micromol/L

Explanation lettering: D = shown as A · C = shown as B · A = shown as C · E = shown as D · B = shown as E

NICE recommends considering a serum urate target below 300 micromol/L in people with tophi or chronic gouty arthritis. Although this patient's level is below the usual target of 360 micromol/L, it remains above the appropriate lower target for his tophaceous disease. During active dose titration, serum urate should be measured monthly and used to guide further dose increases as tolerated. A is incorrect because annual monitoring is appropriate only after the relevant target has been reached. B applies the usual target below 360 micromol/L and therefore undertreats his higher crystal burden. C identifies the correct target but uses an inappropriate monitoring interval during titration. D combines the correct target, treatment sequence and monitoring frequency. E is premature because allopurinol is tolerated, is producing a biochemical response and has not yet been fully titrated. His previous myocardial infarction also supports retaining allopurinol as the preferred first-line xanthine oxidase inhibitor. Chronic kidney disease G3a warrants cautious initiation and escalation but does not, by itself, justify accepting an above-target serum urate concentration or switching immediately to febuxostat.

Reference: Gout: diagnosis and management — Recommendations (9 June 2022) — https://www.nice.org.uk/guidance/ng219/chapter/Recommendations Allopurinol Tablets BP 300 mg — Summary of Product Characteristics (18 November 2025) — https://www.medicines.org.uk/emc/product/14284/smpc