American Board of Internal Medicine (ABIM) Certification Practice Exam

Which clinical circumstances warrant urate-lowering therapy in gout patients according to ACR and EULAR recommendations?

1. Stage 1 CKD

2. Less than 2 acute attacks per year

3. Presence of tophi

4. Uric acid levels below 6 mg/dL

The correct answer is: Presence of tophi

The presence of tophi is a significant factor in determining the need for urate-lowering therapy in patients with gout. Tophi are deposits of monosodium urate crystals that form in tissues due to chronically elevated levels of uric acid. Their presence indicates a more severe and chronic form of gout that may lead to joint damage and other complications if not treated appropriately. The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) guidelines recommend initiating urate-lowering therapy in patients with tophi, even if they do not have active flares or symptoms at the time. This proactive approach aims to prevent further deposition of uric acid crystals and mitigate the risk of future attacks, thus improving the patient's overall quality of life. In contrast, other considerations such as stage 1 chronic kidney disease (CKD), fewer than two acute attacks per year, and uric acid levels below 6 mg/dL do not universally warrant the initiation of urate-lowering therapy. While these factors can guide management, they do not indicate an immediate need for therapy in the same way the presence of tophi does.