A 68-year-old man with gout on allopurinol 300 mg/day presents with a serum urate of 7.8 mg/dL. He has stage 3a CKD (eGFR 52 mL/min). Target serum urate for a patient with recurrent tophaceous gout is less than 5 mg/dL per current guidelines. What is the most appropriate next step?

• A Switch to febuxostat 80 mg/day
• B Add probenecid
• C Increase allopurinol dose (titrate upward monitoring for toxicity) ✓
• D Start pegloticase infusion

Explanation

ACR 2020 gout guidelines recommend allopurinol as the preferred first-line urate-lowering therapy regardless of CKD stage. The dose should be titrated upward (starting low, increasing every 2–4 weeks) targeting serum urate below 5 mg/dL in tophaceous gout, with monitoring for allopurinol hypersensitivity syndrome. Febuxostat 80 mg is effective but the CARES trial raised cardiovascular mortality concern; it is a second-line agent. Probenecid is ineffective in CKD with eGFR <45. Pegloticase is reserved for refractory tophaceous gout failing conventional ULT.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.