A 48-year-old man presents with recurrent attacks of exquisitely painful right first MTP joint swelling. Serum uric acid is 9.8 mg/dL. Joint aspirate shows negatively birefringent needle-shaped crystals. He has a creatinine of 1.9 mg/dL (eGFR 38 mL/min). Which urate-lowering therapy is most appropriate?

• A Probenecid
• B Febuxostat 80 mg/day immediately
• C Benzbromarone
• D Allopurinol starting at 100 mg/day, titrated to target SUA <6 mg/dL ✓

Explanation

Allopurinol is the preferred first-line urate-lowering agent in CKD; it should be started at a low dose (50–100 mg/day) and titrated slowly (every 2–5 weeks) to target serum uric acid <6 mg/dL (<5 mg/dL in tophaceous gout). Dose adjustment for CKD is to start low, but the target SUA, not a fixed dose, guides titration. Probenecid is contraindicated with eGFR <30 mL/min and less effective in CKD. Febuxostat carries increased cardiovascular mortality risk (CARES trial) and is not first-line; benzbromarone is not available in India/internationally.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.