Initiation of allopurinol is appropriate for this patient with gout who has had two attacks of podagra within the past year. The American College of Rheumatology (ACR) guidelines currently recommend that urate-lowering therapy should be initiated in patients with gout who have had two or more attacks within a 1-year period, one attack in the setting of chronic kidney disease of stage 2 or worse, one attack with the presence of tophi visible on examination or imaging, or one attack with a history of urolithiasis. Allopurinol, a xanthine oxidase inhibitor, is an appropriate first-line agent for urate reduction. Flare prophylaxis should be maintained when urate-lowering therapy is undertaken.

Low-dose aspirin can increase serum urate due to effects on renal uric acid transport; however, the ACR does not currently recommend aspirin discontinuation in patients for whom it is indicated, such as this patient with coronary artery disease.

This patient needs to begin urate-lowering therapy, and his flare prophylaxis (colchicine) should be maintained during this period given the paradoxical increased risk of flare during acute serum urate reduction. In the absence of active disease, the ACR currently recommends that prophylaxis should be continued for the greater of the following: 6 months; 3 months after achieving the target serum urate level for a patient without tophi; or 6 months after achieving the target serum urate level where there has been resolution of tophi.

Probenecid is a uricosuric agent (promotes kidney uric acid excretion) and is a viable alternative first-line urate-lowering agent in patients who cannot tolerate or have a contraindication to xanthine oxidase inhibitor therapy. However, allopurinol is generally more appropriate in patients such as in this case who have no contraindication to urate-lowering therapy. Moreover, the patient's history of urolithiasis makes probenecid relatively contraindicated because this medication increases the risk of kidney stones.