A 50-year-old presents with acute monoarthritis of the first MTP joint with severe pain and swelling. Synovial fluid aspirate shows negatively birefringent needle-shaped crystals under polarised light microscopy. The diagnosis is gout. When should urate-lowering therapy (ULT) be initiated?

• A During the acute attack to immediately reduce serum urate and terminate the attack
• B Never; dietary modification alone is sufficient for gout management
• C Immediately after the first attack in all patients
• D Only after ≥ 2 attacks per year, tophi, or urate nephropathy; ULT deferred 2–4 weeks after the acute attack has fully resolved ✓

Explanation

ACR/EULAR guidelines recommend initiating ULT when there are ≥ 2 gout attacks/year, tophi, chronic gouty arthritis, or urate nephropathy/urolithiasis. Crucially, ULT (allopurinol or febuxostat) should NOT be started during an acute attack because rapid serum urate reduction mobilises crystal deposits and can precipitate or prolong acute attacks. ULT initiation is deferred until the acute attack fully resolves (typically 2–4 weeks), with colchicine or NSAIDs continued as prophylaxis during the first 3–6 months of ULT.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.