A 55-year-old man presents with episodic severe pain in the first MTP joint. Serum urate is 9.8 mg/dL. He has two gout flares in the past 6 months. His GFR is 45 mL/min. Which urate-lowering therapy is most appropriate as first-line?
- A Allopurinol starting at low dose (50–100 mg) with gradual uptitration ✓
- B Probenecid 500 mg twice daily
- C Febuxostat 80 mg once daily
- D Rasburicase IV infusion for rapid urate lowering
Explanation
Allopurinol is the first-line urate-lowering therapy for gout per ACR 2020 guidelines, including in CKD patients (GFR <60 mL/min). The critical principle is to start at a very low dose (50 mg daily in CKD) and titrate slowly every 2–4 weeks to target serum urate <6 mg/dL, because rapid dose escalation increases risk of allopurinol hypersensitivity syndrome (AHS), especially in CKD and Southeast Asian patients carrying HLA-B*5801. Probenecid is contraindicated in CKD with GFR <30 and not preferred at GFR 45. Febuxostat is an alternative but carries FDA warnings for cardiovascular death (CARES trial), making it second-line. Rasburicase is for tumour lysis syndrome, not chronic gout.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.