A patient with chronic gout is started on allopurinol for long-term urate-lowering therapy. Within 2 weeks, he develops an acute gout flare. What is the recommended management strategy for this flare, and what prophylactic measure should have been initiated?
- A Stop allopurinol immediately and treat the flare with corticosteroids; allopurinol should never be started during an active flare
- B Switch to febuxostat because allopurinol is causing the flare; no prophylaxis is needed with febuxostat
- C Continue allopurinol and treat the flare with NSAIDs or colchicine; prophylaxis with low-dose colchicine or NSAID should have been started when allopurinol was initiated ✓
- D Increase the allopurinol dose to rapidly lower urate; the flare indicates undertreatment
Correct answer: C. Continue allopurinol and treat the flare with NSAIDs or colchicine; prophylaxis with low-dose colchicine or NSAID should have been started when allopurinol was initiated
Explanation
Initiating urate-lowering therapy (allopurinol or febuxostat) commonly precipitates acute gout flares due to mobilization of urate from tissue deposits. Guidelines recommend starting prophylaxis with low-dose colchicine (0.5 mg BD) or a low-dose NSAID for at least 3 to 6 months when initiating urate-lowering therapy. Allopurinol should NOT be stopped during a flare; it is continued while the flare is treated separately.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.