How would you approach the management of a patient with tophaceous gout who consistently has a serum uric acid under 5 on allopurinol but continues to experience gout flares?

I have a slightly different take on this question than Dr. @Dr. First Last. We don’t know from the question when allopurinol was started, what the current dose is or if the patient’s gout is tophaceous. Flares are commonly seen for several months after oral uric acid lowering therapy (ULT) is initiated. MSU deposits take a while to clear and the more deposits, the longer it will be before flares abate. It may take much longer in the patient with extensive, palpable tophaceous deposits. So, resol...

In a case like this, the recurrent gout flares are likely coming from MSU crystal micro tophi already present within the joint. If the renal function is normal, I would continue the prophylactic colchicine, 0.6 mg daily until these micro tophi are significantly dissolved and the flare-ups become less and less common while continuing urate-lowering therapy. If there is CKD, then the use of prophylactic colchicine becomes more difficult, and it may have to be administered every other day, 2-3 time...