A 68-year-old man presents with severe acute monoarthritis of the first MTP joint. Serum uric acid is 9.8 mg/dL. He has a history of stage 3 CKD and is currently on aspirin 81 mg/day for CAD. Which urate-lowering therapy (ULT) is PREFERRED as first-line in this patient?
- A Allopurinol, starting at 50–100 mg/day and titrating to target serum uric acid < 6 mg/dL ✓
- B Febuxostat 80 mg/day immediately
- C Probenecid 500 mg twice daily
- D Rasburicase IV infusion
Explanation
Allopurinol remains the first-line ULT for gout per ACR 2020 guidelines, even in CKD (dose adjustment required). Starting at a low dose (50–100 mg/day) and titrating upward to achieve serum uric acid < 6 mg/dL minimises the risk of allopurinol hypersensitivity syndrome, which is more common with rapid dose escalation. Febuxostat may be used if allopurinol is not tolerated, but the CARES trial showed an increase in cardiovascular death with febuxostat in patients with established cardiovascular disease — this patient has CAD making febuxostat a less safe choice despite the subsequent FDA label revision. Probenecid is a uricosuric agent contraindicated in CKD (eGFR < 50). Rasburicase is for tumour lysis syndrome, not gout.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.