Tophaceous gout results from chronic monosodium urate crystal deposition. Which serum urate target is recommended per ACR 2020 guidelines to dissolve tophi and prevent recurrent gout attacks?

• A < 6.0 mg/dL for all patients requiring urate-lowering therapy
• B < 7.0 mg/dL (normal upper limit) for all gout patients
• C < 4.0 mg/dL for all patients with tophaceous gout
• D < 5.0 mg/dL for patients with tophi or frequent attacks; < 6.0 mg/dL for others ✓

Explanation

The ACR 2020 gout guidelines recommend a treat-to-target approach: serum urate < 6.0 mg/dL for most patients on urate-lowering therapy (ULT), but < 5.0 mg/dL for patients with frequent attacks (≥2/year), tophi, or radiographic damage, as lower urate levels accelerate tophus dissolution (which requires supersaturation reversal). Allopurinol is the first-line ULT; febuxostat is second-line. Target levels below saturation (6.8 mg/dL) are required to prevent new crystal deposition; going below 5 mg/dL accelerates existing crystal resorption.

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

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Written and medically reviewed by the StethoPrep medical team.