Management of Gout with Hyperuricemia

Initial Assessment and Workup

The American College of Physicians recommends calculating estimated glomerular filtration rate (eGFR) to assess renal function, which determines allopurinol dosing 1
Patients with gout should be screened for comorbidities, including coronary heart disease, heart failure, stroke, peripheral arterial disease, diabetes, obesity, hyperlipidemia, and hypertension 1, 2
For patients with gout onset before age 25 or history of kidney stones, a 24-hour urine uric acid collection should be obtained to screen for uric acid overproduction 1, 3, 4
All medications should be reviewed and non-essential drugs that elevate uric acid, such as thiazide and loop diuretics, niacin, and calcineurin inhibitors, should be eliminated 3, 4

The American College of Internal Medicine recommends using NSAIDs, colchicine, or corticosteroids to treat acute gout attacks, with the choice of treatment depending on patient comorbidities 5
NSAIDs should be initiated immediately at full anti-inflammatory doses 5
Colchicine should be used at a low dose (0.5-1 mg daily) to minimize gastrointestinal side effects 5
Corticosteroids (oral or intra-articular) are particularly useful when NSAIDs and colchicine are contraindicated 5

The American College of Physicians recommends avoiding alcohol, especially beer and spirits, to reduce the risk of gout attacks 2
Sugar-sweetened beverages and high-fructose corn syrup should also be avoided 2, 6
Purine-rich meats (red meat, organ meats) and seafood should be limited 2, 6
Low-fat dairy products, weight loss if overweight or obese, regular physical activity, and adequate hydration (at least 2 liters daily urinary output) are encouraged 2

The American College of Physicians recommends targeting serum uric acid levels below 6 mg/dL for all patients with gout, with more aggressive targets (<5 mg/dL) for patients with severe disease, tophi, or chronic tophaceous gout 1, 2, 7
Allopurinol should be initiated at a dose of 100 mg daily and titrated upward every 2-4 weeks until the target uric acid level is achieved 1, 2, 7
Febuxostat can be used as an alternative xanthine oxidase inhibitor if allopurinol is not tolerated or fails to achieve target uric acid levels 2, 7, 8

The American College of Internal Medicine recommends mandatory flare prophylaxis for at least 6 months when initiating urate-lowering therapy, with colchicine (0.5-1 mg daily) as the first choice 1, 5, 7
Low-dose NSAIDs can be used as an alternative if colchicine is contraindicated or not tolerated 1, 7

Serum uric acid levels should be monitored every 2-4 weeks during dose titration and regularly once the target is achieved 1, 7
Urate-lowering therapy should be continued indefinitely to maintain target uric acid levels and prevent acute gout attacks 1, 7

Specialist referral should be considered for patients with unclear etiology of hyperuricemia, refractory signs or symptoms despite appropriate therapy, difficulty reaching target uric acid level, or multiple or serious adverse events from urate-lowering therapy 3, 4