A 50-year-old man with known gout presents with a serum urate of 9.8 mg/dL despite allopurinol 300 mg/day. Renal function is normal. He has frequent flares. What is the MOST appropriate next step in urate-lowering therapy?
- A Increase allopurinol dose to 600–900 mg/day ✓
- B Add colchicine indefinitely
- C Switch to febuxostat 80 mg/day
- D Add probenecid
Explanation
Current ACR and EULAR guidelines recommend titrating allopurinol up to the maximum tolerated dose (up to 800–900 mg/day in normal renal function) before switching agents, as many patients are undertreated on fixed 300 mg doses. The target serum urate is <6 mg/dL (<5 mg/dL in tophaceous gout). Febuxostat is an alternative if allopurinol is not tolerated or contraindicated (though CARES trial raised CV concerns). Probenecid is a uricosuric used when patients are underexcretors and renal function is adequate, but up-titrating allopurinol is the first step. Colchicine is used for flare prophylaxis, not urate lowering.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.