A 50-year-old man presents with acute monoarthritis of the first MTP joint, erythema and extreme tenderness. Serum uric acid is 9.8 mg/dL. Joint aspiration shows negatively birefringent needle-shaped crystals. He has CKD stage 3 (eGFR 42). Which urate-lowering therapy is first-line with dose adjustment in CKD?
- A Allopurinol, starting low (50–100 mg/day) and titrating to target uric acid <6 mg/dL ✓
- B Probenecid
- C Febuxostat
- D Rasburicase
Explanation
Allopurinol remains first-line urate-lowering therapy even in CKD; the key principle is to start at a low dose (50–100 mg/day) and titrate slowly every 2–4 weeks to achieve the target serum uric acid <6 mg/dL (<5 mg/dL in tophaceous gout), regardless of eGFR. Previous guidance to cap allopurinol at the eGFR-based dose has been superseded by evidence that dose capping prevents target attainment. Probenecid is contraindicated below eGFR <30 and ineffective in CKD. Febuxostat is an alternative but the FAST trial raised cardiovascular mortality concerns in patients with established CVD. Rasburicase is used for tumor lysis syndrome.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.