The allopurinol dose should be increased for this patient with gout who has not yet reached the serum urate target goal of less than 6.0 mg/dL (0.35 mmol/L). Allopurinol is considered a first-line agent for serum urate reduction in patients with gout. Historically, concern has been expressed regarding allopurinol dosing and the risk of hypersensitivity reaction; however, it appears that gradual dose escalation with monitoring for side effects is a safe approach, even in patients with chronic kidney disease. Recent American College of Rheumatology recommendations advocate for a starting dose of 100 mg/d (or 50 mg/d in those with stage 4 or 5 chronic kidney disease) with titration upward every 2 to 5 weeks, aiming for a target serum urate level of less than 6.0 mg/dL (0.35 mmol/L). Despite the patient's kidney dysfunction, it is safe to up titrate the allopurinol gradually over several months to reach the target goal. If intolerance to allopurinol emerges, alternative urate-lowering therapy (such as the xanthine oxidase inhibitor febuxostat) should be pursued.

Gout flare prophylaxis such as colchicine should be maintained during urate-lowering therapy because patients are paradoxically at increased risk of gout flares during this time.

This patient is taking losartan to treat hypertension. This agent should not be discontinued because it has uricosuric effects and thus may be helping with efforts to lower his serum urate level.

This patient is not yet at the target serum urate goal; therefore, continuation of the same therapy is not appropriate.