A patient with gout has a serum uric acid of 9.8 mg/dL, two attacks in the past year, and one visible tophus on the left elbow. When should urate-lowering therapy (ULT) be initiated, and what serum uric acid target should be achieved?
- A Start ULT immediately during the acute attack; target < 6 mg/dL
- B Defer ULT until the patient has three or more attacks per year
- C Start ULT when the acute attack has resolved; target < 6 mg/dL (or < 5 mg/dL if tophi present) ✓
- D Start ULT when the acute attack has resolved; target < 7 mg/dL
Correct answer: C. Start ULT when the acute attack has resolved; target < 6 mg/dL (or < 5 mg/dL if tophi present)
Explanation
According to ACR 2020 and EULAR 2016/2022 gout guidelines, ULT should be initiated after the acute flare has resolved (ideally at 2–4 weeks). The treat-to-target serum uric acid is < 6 mg/dL for most patients, but < 5 mg/dL is recommended when tophi are present to accelerate tophus resolution. Starting ULT during an acute attack may prolong or worsen the flare. A target of < 7 mg/dL is insufficient to dissolve crystals. There is no requirement to wait for three attacks before initiating ULT when tophi are already present.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.