Nokea
Mr Yee, a 45-year-old, reports three recent gout attacks in the ankle or knee. You notice a small tophus over the left elbow. He says that two years ago he took allopurinol 100 mg for one month, then 200 mg OM for one month but stopped as it 'did not help his gout and there was no improvement'. When you probe, he states that he was not very adherent to allopurinol either then as it was some years ago, and he says he probably took it 'once or twice a week'. He states he did not experience any rashes or other side effects to it then. He does not drink alcohol except one glass of wine once or twice a year on special occasions. He has past history of renal stones and also underlying ischaemic cardiomyopathy for which he is still being followed up by the cardiologist. Two weeks ago, he was admitted to the hospital for a gout flare. He had a blood test done, with the following results: Uric acid 620 mmol/L, Creatinine 120 umol/L, eGFR 55 mL/min, BP 144/94 mmHg, he has Hypertension on HCTZ long-term. He is asking you to give him Arcoxia 120 mg OM standby as it usually works for his gout flare. Which is correct advice?
Correct Answer: B
Rationale: Tophus and frequent flares with uric acid 620 mmol/L indicate chronic gout needing ULT. Prior allopurinol failure' likely stems from non-adherence (once/twice weekly), not ineffectiveness. Stepwise up-titration of allopurinol, starting low (e.g., 100 mg) due to eGFR 55, with regular blood tests (uric acid, creatinine), targets <360 mmol/L safely, per ACR guidelines. HLA-B5801 testing is for high-risk groups (e.g., Han Chinese) before allopurinol, not febuxostat-specific here. Colchicine helps, but increasing HCTZ (urate-retaining) may worsen gout. Probenecid suits renal underexcretors, not proven here. This approach optimizes chronic gout control.