A 32-year-old man with a past medical history of gout presents to the rheumatology clinic complaining about multiple gout flares in the recent 6 months. He was initially diagnosed with crystal-proven gout 2 years ago after an arthrocentesis and was eventually started on allopurinol 100 mg orally daily. However, he did not tolerate allopurinol, and the medication was stopped. Currently, he takes ibuprofen 400 mg three times daily every time he gets a gout flare. His serum urate levels are 8.0 mg /dl and there is slight worsening of his renal function on recent labs.
Which of the following medication regimens should be considered for long-term gout management in this patient?
- A) Continue using ibuprofen 400 mg three times daily as needed
- B) Reinitiate allopurinol 100 mg daily
- C) Start allopurinol 50 mg daily as the patient was unable to tolerate a higher dose before
- D) Start febuxostat 80 mg daily
- E) Start probenecid 500 mg daily
D) Start febuxostat 80 mg daily
The patient’s gout is uncontrolled and his serum urate level is elevated. It should be below 6 mg/dl. Allopurinol is the first-line agent to control gout long term. However, this patient is unable to tolerate the medication due to side effects. In such a case, consider initiating febuxostat 80mg daily and, if necessary, increase after 4 weeks to 120 mg/day as an alternative xanthine oxidase inhibitor in patients not tolerating allopurinol or if renal impairment prevents the allopurinol dose elevation needed to achieve the desired serum urate level.
Answer choice A: Continue using ibuprofen 400 mg three times daily as needed, is incorrect. Ibuprofen is an anti-inflammatory agent and may be used for acute gout attacks but not for not chronic management. Chronically being on NSAIDs such as ibuprofen makes one prone to gastrointestinal and renal side effects. Also, NSAIDs will not lower uric acid, and the patient is noted to have slight worsening renal function.
Answer choice B: Reinitiate allopurinol 100 mg daily, is incorrect. There is limited benefit for initiating allopurinol again since the patient could not tolerate it before and now has slightly worsening renal function.
Answer choice C: Start allopurinol 50 mg daily as the patient was unable to tolerate a higher dosie before, is incorrect. As noted above, there is no need to start allopurinol since the patient is prone to side effects and now has slight worsening renal function.
Answer choice E: Start probencid 500 mg daily, is incorrect. Probenecid is seldom used to control serum uric acid and is not the preferred initial agent for chronic management of gout.
Key Learning Point
The American College of Rheumatology Guideline for the Management of Gout: For patients starting any urate-lowering therapy, xanthine oxidase inhibitors such as allopurinol are recommended over all other urate-lowering therapy as the preferred first-line agents if there are no contraindications.
Dr. Raj Dasgupta