Rheumatology for MRCPI Part 1

A 52-year-old man with a history of gout and hypertension has a third attack this year. Serum urate between attacks is 520 micromol/L. He takes bendroflumethiazide. His last acute attack settled two weeks ago and he is currently pain-free. What is the most appropriate management?

1. Start febuxostat as first-line therapy Second line rather than first. Febuxostat is used where allopurinol is not tolerated or is ineffective, and carries cardiovascular safety considerations in patients with established cardiovascular disease.
2. Start allopurinol with colchicine cover, and review the thiazide correct Correct. Recurrent attacks are an indication for urate-lowering therapy, started once the acute attack has settled. Prophylactic colchicine for the first months prevents the paradoxical flare that urate lowering triggers, and the thiazide raises urate and should be reconsidered.
3. Start allopurinol during the next acute attack Wrong convention. Traditionally urate-lowering therapy is not initiated during an acute flare, although once established it should never be stopped during one.
4. Dietary purine restriction alone Insufficient. Diet has a modest effect on serum urate compared with the genetic and drug contributions, and it will not achieve a target of below 360 micromol/L.
5. Long-term daily NSAIDs without urate-lowering therapy Wrong. It treats the symptom while the urate burden and the tophi continue to accumulate, and it exposes a hypertensive patient to renal and gastrointestinal harm.

The point: Urate-lowering therapy for recurrent attacks, tophi, urate stones or chronic arthropathy. Target below 360 micromol/L, or below 300 with tophi. Titrate allopurinol upwards rather than fixing at 300 mg, cover with colchicine, and never stop it during a flare.

Source: BSR guideline for the management of gout British Society for Rheumatology · tier 2, specialty society or college