A 58-year-old man presents with acute monoarthritis of the first metatarsophalangeal joint, serum urate 9.2 mg/dL, and a prior episode 8 months ago. He is on hydrochlorothiazide for hypertension. After managing the acute attack, which drug is preferred for urate-lowering therapy given his reduced eGFR of 48 mL/min?
- A Probenecid
- B Benzbromarone
- C Febuxostat ✓
- D High-dose aspirin
Correct answer: C. Febuxostat
Explanation
Febuxostat is a non-purine xanthine oxidase inhibitor that does not require dose adjustment in mild-to-moderate CKD (eGFR > 30) and is preferred over allopurinol when allopurinol is not tolerated or in CKD. Probenecid and other uricosurics are ineffective when eGFR < 50 mL/min. Benzbromarone carries hepatotoxicity concerns. High-dose aspirin is uricosuric but clinically impractical and not used for ULT. Additionally, hydrochlorothiazide should be substituted with losartan (which is itself mildly uricosuric).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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