A 68-year-old man presents with sudden severe right toe pain, swelling, and redness. Serum uric acid is 9.2 mg/dL. He is on hydrochlorothiazide for hypertension. Synovial fluid shows negatively birefringent, needle-shaped crystals. During the acute attack, the MOST appropriate anti-inflammatory agent given his normal renal function is:
- A Start allopurinol immediately
- B Probenecid
- C Oral colchicine 1.2 mg followed by 0.6 mg one hour later ✓
- D Rasburicase
Correct answer: C. Oral colchicine 1.2 mg followed by 0.6 mg one hour later
Explanation
For acute gout flares, the 2020 ACR guidelines recommend colchicine, NSAIDs, or oral corticosteroids as first-line agents with equivalent efficacy. Low-dose colchicine (1.2 mg then 0.6 mg 1 hour later) is preferred because it has equivalent efficacy to high-dose with significantly fewer gastrointestinal side effects (AGREE trial). Allopurinol should NOT be started during an acute attack as it can precipitate or prolong the flare; it is initiated 2–4 weeks after resolution. Probenecid is a uricosuric for maintenance. Rasburicase is used for tumor lysis syndrome.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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