A 48-year-old man with a 20-year history of tophaceous gout presents with acute monoarthritis. His serum urate is 9.2 mg/dL. He has stage 3b CKD (eGFR 35) and is on hydrochlorothiazide for hypertension. The urate-lowering drug of choice in this patient with CKD, based on CARES and FAST trials evidence, is:
- A Allopurinol 300 mg/day ✓
- B Febuxostat 80 mg/day
- C Probenecid 500 mg twice daily
- D Rasburicase IV for rapid urate lowering
Explanation
Despite the CARES trial showing increased cardiovascular mortality with febuxostat vs allopurinol in patients with established CVD/CV risk, the FAST trial (UK, 2020) found no significant difference in all-cause mortality between febuxostat and allopurinol. However, current EULAR 2022 and ACR 2020 gout guidelines still recommend allopurinol as first-line ULT, with careful dose-escalation to target serum urate <6 mg/dL (in tophaceous gout <5 mg/dL). In CKD, allopurinol dose starts low (50–100 mg/day) and is slowly titrated based on tolerability; febuxostat does not require dose adjustment in mild-moderate CKD. Probenecid is ineffective in CKD (eGFR <30). Rasburicase is for tumor lysis syndrome.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.