A 68-year-old man with a long history of poorly controlled gout develops 'tophaceous' deposits. Serum urate is 9.2 mg/dL on maximum dose allopurinol. He has stage 3 CKD. What is the MOST appropriate treatment escalation?

• A Switch to febuxostat ✓
• B Add probenecid
• C Increase allopurinol with target uric acid < 5 mg/dL
• D Add rasburicase infusion monthly

Explanation

Febuxostat (a non-purine selective xanthine oxidase inhibitor) is the preferred alternative when allopurinol is inadequate or not tolerated. Febuxostat does not require dose adjustment for mild-moderate CKD (eGFR > 30 mL/min), unlike allopurinol which requires dose reduction in CKD (increased oxypurinol accumulation causing toxicity). Probenecid is a uricosuric and is contraindicated in CKD (eGFR < 30) and tophaceous gout with overproduction. Rasburicase (recombinant uricase) is used for acute tumor lysis syndrome, not chronic gout management.

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

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Written and medically reviewed by the StethoPrep medical team.