skip to main content

First gout flare with marked hyperuricemia and stage 3 chronic kidney disease — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

HardGoutFirst gout flare with marked hyperuricemia and stage 3 chronic kidney diseaseABIM Board

A 63-year-old African American man is evaluated after his first episode of acute gout. Arthrocentesis of the first metatarsophalangeal joint showed needle-shaped, negatively birefringent crystals; Gram stain and culture were negative. The flare resolved after intra-articular glucocorticoid administration. Two weeks later, his serum urate level is 10.3 mg/dL. He has stable stage 3b chronic kidney disease with an estimated glomerular filtration rate of 38 mL/min/1.73 m². He has no history of nephrolithiasis, cardiovascular disease, or prior exposure to urate-lowering therapy. Which of the following is the most appropriate long-term management plan?

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

Reveal the answer and explanation

Correct answer: A — Test for HLA-B*58:01 and, if negative, begin low-dose allopurinol with anti-inflammatory prophylaxis and titrate therapy to a serum urate level below 6 mg/dL

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

Although urate-lowering therapy is generally deferred after an uncomplicated first gout flare, this patient has two guideline-recognized exceptions: stage 3 chronic kidney disease and marked hyperuricemia above 9 mg/dL. Long-term therapy should therefore be discussed and initiated. Allopurinol remains the preferred first-line urate-lowering drug in stage 3 or worse CKD; renal impairment is not an indication to select probenecid or febuxostat first. Because the patient is African American, HLA-B*58:01 testing is recommended before allopurinol initiation due to the increased prevalence of this allele and its association with allopurinol hypersensitivity syndrome. If testing is negative, allopurinol should be started at no more than 100 mg/day—and a lower dose may be considered in CKD—then titrated using serial serum urate measurements to a target below 6 mg/dL. Anti-inflammatory prophylaxis should accompany initiation for at least 3–6 months. A is inappropriate because CKD and a serum urate level above 9 mg/dL justify therapy even after a first flare. B is inferior because xanthine oxidase inhibitors are preferred over probenecid in stage 3 CKD. C omits the preferred initial allopurinol strategy; febuxostat is generally reserved for patients in whom allopurinol is unsuitable. D appropriately obtains genetic testing but begins allopurinol at an unnecessarily high dose, increasing hypersensitivity and flare risk.

Reference: 2020 American College of Rheumatology Guideline for the Management of Gout (2020) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10563586/ HLA-B*58:01 and Risk of Allopurinol-Induced Severe Cutaneous Adverse Reactions in the US (2025) — https://pubmed.ncbi.nlm.nih.gov/41160012/