RheumWorld™

A 50-year-old man presents with severe pain, redness, and swelling of his right great toe that began abruptly two days ago. He describes the pain as excruciating (9/10), noting it woke him from sleep and that even the weight of a bedsheet is intolerable. He denies preceding trauma, fever, or similar past episodes.

His past medical history is notable for stage 2 chronic kidney disease with a baseline creatinine of 1.4 mg/dL (eGFR ~65 mL/min/1.73m²). He has no hypertension, diabetes, or cardiovascular disease. He takes no regular medications and does not use diuretics. He drinks 1-2 beers per week. There is no family history of gout or kidney stones.

Physical examination reveals an afebrile man in moderate distress. Vital signs are stable. There is marked erythema, warmth, swelling, and exquisite tenderness over the right first metatarsophalangeal (MTP) joint without overlying skin breakdown. No other joints are involved, and no tophi are present.

Laboratory studies:

• Serum uric acid: 9.5 mg/dL (normal <7.0)
• Creatinine: 1.4 mg/dL
• eGFR: 65 mL/min/1.73m²
• White blood cell count: 8,200/µL
• C-reactive protein: 1.6 mg/dL

Synovial fluid analysis shows a leukocyte count of 18,000/µL with neutrophilic predominance. Microscopy reveals needle-shaped, negatively birefringent monosodium urate crystals.

He is treated with colchicine, and his symptoms resolve over the next week. He returns to discuss long-term management.

According to the 2020 American College of Rheumatology (ACR) guidelines, what is the recommendation regarding initiation of urate-lowering therapy (ULT) for this patient after his first gout flare has resolved?