Rheumatology Question 1

A 59-year-old man is evaluated for a 6-month history of gout. He was doing well on colchicine and allopurinol but developed hypersensitivity to allopurinol, which resolved with cessation of the agent. He then began to have more frequent gout flares; two flares occurred in the past month and were treated with prednisone. History is also significant for hypertension, chronic kidney disease, and dyslipidemia. Current medications are colchicine, lisinopril, metoprolol, and simvastatin.

On physical examination, temperature is 37.2 °C (98.9 °F), blood pressure is 142/86 mm Hg, pulse rate is 64/min, and respiration rate is 12/min. BMI is 30. The remainder of the examination is normal.

Laboratory studies reveal a serum creatinine level of 2.3 mg/dL (203.3 µmol/L), a serum urate level of 9.2 mg/dL (0.54 mmol/L), and normal liver chemistry studies; estimated glomerular filtration rate is 48 mL/min/1.73 m2.

Which of the following is the most appropriate next step in management?

A  Discontinue colchicine

B  Start febuxostat

C  Start pegloticase

D  Start probenecid

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