A 55-year-old man with tophaceous gout takes allopurinol 300 mg daily and is listed for elective total knee replacement next week. He has had no acute flares for six months. How should his urate-lowering therapy be managed around surgery?

• A Continue allopurinol uninterrupted through the perioperative period ✓
• B Stop allopurinol three days before surgery and restart one week after
• C Switch to probenecid for two weeks before surgery
• D Start prednisone 60 mg daily postoperatively to prevent flare

Explanation

Established urate-lowering therapy should be continued without interruption through surgery, since abrupt cessation destabilizes serum urate and precipitates flares, while continuation does not impair wound healing. Stopping allopurinol, option B, is precisely the maneuver that triggers rebound attacks. Probenecid is ineffective at low renal urate clearance and inappropriate perioperatively. High-dose steroids are reserved for treating an actual flare, not routine prophylaxis. Starting new urate-lowering drugs during an acute attack is avoided, but continuing established therapy is not.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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