American Board of Internal Medicine (ABIM) Certification Practice Exam

In managing acute gout, when should dose adjustments to allopurinol be considered?

1. Immediately during an acute attack

2. After 1 week post-attack

3. 3-4 weeks after the inflammation subsides

4. Never during an active attack

The correct answer is: 3-4 weeks after the inflammation subsides

The timing of dose adjustments to allopurinol in the management of acute gout is critical to ensuring effective treatment and minimizing flare-ups. Allopurinol is a xanthine oxidase inhibitor used for long-term management of hyperuricemia and prevention of gout attacks. Initiating or adjusting the dose of allopurinol during an active gout attack is not advisable, as this may exacerbate the inflammation and prolong the acute attack. After an acute attack, inflammation and pain typically subside over a period of days to weeks. Once the patient is relatively symptom-free and has returned to a stable state, it is appropriate to reassess the management plan and consider adjusting the allopurinol dose. Adjustments made at this juncture—generally around 3 to 4 weeks post-attack—can help maintain serum urate levels in the desired range and reduce the risk of future gout attacks. The rationale for waiting until after the attack has resolved is partly due to the fact that urate levels can fluctuate significantly during acute inflammation, which could lead to misleading assessments if dose adjustments are made too early. This approach helps to optimize the treatment of gout in the long term while allowing the patient to recover fully from the acute episode.