Hyperuricemia Management

Initial Assessment and Evaluation

The American College of Cardiology recommends performing a thorough clinical evaluation of disease activity through history and physical examination for symptoms of arthritis, presence of tophi, and signs of acute or chronic synovitis 1
Screen for causes of hyperuricemia, including comorbidities and medications that can elevate uric acid, such as thiazides, loop diuretics, niacin, and calcineurin inhibitors, as suggested by the European Heart Journal 1, 2
Consider urine uric acid evaluation for patients with gout onset before age 25 or history of urolithiasis to screen for uric acid overproduction 1

Limit consumption of purine-rich meats and seafood to reduce uric acid levels [1, 2 is not available for this fact, but 1 is]
Avoid high fructose corn syrup sweetened beverages and energy drinks 1

Allopurinol is recommended as the first-line XOI, starting at 100 mg daily and titrating upward every 2-5 weeks to reach target serum urate level, as recommended by the American College of Rheumatology 1
Febuxostat is an alternative XOI with similar efficacy when allopurinol is not tolerated or contraindicated 1
Probenecid is recommended as an alternative first-line therapy when XOIs are contraindicated or not tolerated 1
Pegloticase is reserved for patients with refractory disease who have failed maximum appropriate doses of XOI and uricosuric combination therapy 1

Monitor serum urate every 2-5 weeks during ULT titration and continue measurements every 6 months once target is achieved to monitor adherence, as suggested by the American College of Rheumatology 1
The target serum urate level should be below 6 mg/dL for all gout patients 1
For patients with greater disease severity and urate burden, target serum urate below 5 mg/dL 1

In patients with chronic kidney disease, xanthine oxidase inhibitors are preferred over uricosuric agents, but dose adjustment is necessary 1
For acute gout flares in CKD patients, low-dose colchicine or glucocorticoids are preferable to NSAIDs 1
For hyperuricemia associated with tumor lysis syndrome, rasburicase is recommended for rapid reduction of uric acid levels, as recommended by the Journal of Clinical Oncology and Haematologica 3, 4
Rasburicase affects rapid and complete degradation of uric acid to allantoin, allowing prompt continuation of chemotherapy 4
Hyperuricemia confers a poor prognosis in heart failure patients, according to the European Heart Journal 2
In acute gout with heart failure, a short course of colchicine may be considered, while NSAIDs should be avoided 2