Hyperuricemia Management and Clinical Consequences

Clinical Consequences of Hyperuricemia

The American College of Rheumatology suggests that uric acid becomes supersaturated and precipitates as monosodium urate crystals when levels exceed 6.8 mg/dL, causing gout attacks 3
Gout manifests initially as acute, episodic arthritis but can progress to chronic arthritis affecting multiple joints, according to the American College of Rheumatology 1
Tophi develop in joints, periarticular tissues, bursae, bone, ears, and skin in chronic disease, as noted by the American College of Rheumatology 1
Patients who maintain uric acid levels below 6.0 mg/dL have approximately 5% risk of acute gout attacks at one year, compared to 10-15% risk in those with levels at or above 6.0 mg/dL, as reported by the American College of Physicians 3
Hyperuricemia increases the risk of new chronic kidney disease diagnoses, with 4% versus 2% at year 1 and 9% versus 5% at year 3 in high versus low uric acid groups, according to the American College of Physicians 3
Uric acid kidney stones occur, typically with acidic urine pH, as noted by the American College of Rheumatology 1
Hyperuricemia is independently associated with hypertension, coronary heart disease, heart failure, stroke, peripheral arterial disease, and cardiovascular mortality, as reported by the European League Against Rheumatism 4

The American College of Rheumatology recommends screening for chronic kidney disease by calculating estimated glomerular filtration rate (eGFR) at diagnosis and monitoring regularly 4
Screen for associated comorbidities, including coronary heart disease, heart failure, stroke, peripheral arterial disease, diabetes, obesity, hyperlipidemia, and hypertension, as suggested by the European League Against Rheumatism 4
For gout onset before age 25 or history of urolithiasis, obtain 24-hour urine uric acid to screen for overproduction, as recommended by the American College of Rheumatology 2
Review and eliminate non-essential medications that elevate uric acid, such as thiazide and loop diuretics, niacin, and calcineurin inhibitors, as noted by the American College of Rheumatology 2
Limit purine-rich meats and seafood, high-fructose corn syrup sweetened beverages, and avoid alcohol, especially beer, as suggested by the American College of Rheumatology 2
Target serum uric acid below 6 mg/dL for all patients, maintained lifelong, as recommended by the American College of Rheumatology 2
Start allopurinol 100 mg daily, increase by 100 mg every 2-4 weeks until target achieved, as suggested by the American College of Rheumatology 2
Adjust dose based on creatinine clearance in renal impairment, as noted by the American College of Rheumatology 5

The American College of Rheumatology recommends targeting serum uric acid below 5 mg/dL until complete crystal dissolution for severe disease with tophi 5
If allopurinol fails to reach target, switch to febuxostat or add uricosuric agent, such as probenecid or sulphinpyrazone, as suggested by the American College of Rheumatology 5
Benzbromarone can be used in mild-to-moderate renal impairment but carries hepatotoxicity risk, as noted by the American College of Rheumatology 5

All patients starting urate-lowering therapy require prophylaxis for the first 6 months, as recommended by the American College of Rheumatology 5
Colchicine 0.5-1 mg daily is first choice, as suggested by the American College of Rheumatology 5
Low-dose NSAIDs are an alternative if colchicine is contraindicated or not tolerated, as noted by the American College of Rheumatology 5

Check serum uric acid every 2-4 weeks during dose titration, as recommended by the American College of Rheumatology 5
Once stable at target, monitor regularly to ensure target is maintained, as suggested by the American College of Rheumatology 5
Continue urate-lowering therapy indefinitely as this is lifelong treatment, as noted by the American College of Rheumatology 5