A 48-year-old man with a 15-year history of severe gout on allopurinol 300 mg/day has a serum urate of 8.4 mg/dL. He has no renal impairment. He cannot tolerate febuxostat due to cardiovascular concerns. According to ACR 2020 guidelines, what is the recommended next step?
- A Add colchicine indefinitely
- B Increase allopurinol dose up to 800 mg/day titrating to target urate <6 mg/dL ✓
- C Switch to probenecid without further dose titration
- D Add pegloticase immediately
Explanation
ACR 2020 gout guidelines strongly recommend a treat-to-target strategy, aiming for serum urate <6 mg/dL (or <5 mg/dL in severe disease). Allopurinol can be dose-escalated up to 800 mg/day (with appropriate monitoring, and lower starting doses in CKD) if the target is not achieved on lower doses. Febuxostat carries cardiovascular warnings but allopurinol dose optimisation should precede switching urate-lowering therapies. Pegloticase is reserved for refractory tophaceous gout not responding to oral urate-lowering therapy. Colchicine prophylaxis is added during flares but does not address hyperuricaemia.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.