A 63-year-old man with gout presents acutely with a hot, swollen first MTP joint (podagra). Serum urate is 10.2 mg/dL. Joint aspiration shows negatively birefringent needle-shaped crystals. Long-term urate-lowering therapy (ULT) should be commenced:
- A Immediately during the acute attack with allopurinol
- B After the acute attack resolves (typically 2–4 weeks), with prophylactic colchicine cover for 3–6 months ✓
- C Only if the patient has tophi — a single attack does not require ULT
- D Lifelong colchicine alone is sufficient without allopurinol
Correct answer: B. After the acute attack resolves (typically 2–4 weeks), with prophylactic colchicine cover for 3–6 months
Explanation
Initiating allopurinol during an acute gout flare can mobilise monosodium urate crystals and prolong or precipitate new attacks; current ACR/EULAR guidelines recommend starting ULT after the acute attack resolves. When ULT is initiated, prophylactic low-dose colchicine (or NSAID) should be co-prescribed for 3–6 months to prevent flares triggered by urate flux. Target serum urate is <6 mg/dL (or <5 mg/dL in tophaceous gout).
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.