Hyperuricemia Treatment Protocol

Initial Assessment and Non-Pharmacologic Approaches

The American College of Rheumatology recommends performing a thorough clinical evaluation of gout disease activity and burden through history and physical examination for symptoms of arthritis, presence of tophi, and signs of acute or chronic synovitis 3
Screening for causes of hyperuricemia, including comorbidities such as obesity, hypertension, diabetes, and hyperlipidemia, and medications that can elevate uric acid, such as thiazides, loop diuretics, niacin, and calcineurin inhibitors, is recommended 4
The American College of Rheumatology suggests considering urine uric acid evaluation for patients with gout onset before age 25 or history of urolithiasis to screen for uric acid overproduction 4

Limiting consumption of purine-rich meats and seafood is recommended to reduce uric acid levels 1
Avoiding high fructose corn syrup sweetened beverages and energy drinks is recommended to reduce uric acid levels 1
Encouraging consumption of low-fat or non-fat dairy products is recommended to reduce uric acid levels 1
Reducing alcohol consumption, particularly beer, and avoiding alcohol overuse is recommended to reduce uric acid levels 1
Complete abstinence from alcohol during periods of active gout arthritis is recommended 1
The European League Against Rheumatism recommends aiming for weight reduction if obese 5

The American College of Rheumatology recommends xanthine oxidase inhibitors (XOIs) as first-line therapy for hyperuricemia in gout, with the goal of achieving serum urate levels below 6 mg/dL 1, 2
Allopurinol is recommended as a first-line XOI, starting at 100 mg daily and titrating upward every 2-5 weeks to reach target serum urate level 2
Febuxostat is recommended as an alternative XOI with similar efficacy 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 7

The American College of Rheumatology recommends monitoring serum urate every 2-5 weeks during ULT titration and continuing measurements every 6 months once target is achieved to monitor adherence 1
The target serum urate level should be below 6 mg/dL for all gout patients, and below 5 mg/dL for patients with greater disease severity and urate burden (tophi, chronic tophaceous gout) 2

In patients with chronic kidney disease, xanthine oxidase inhibitors are preferred over uricosuric agents 6
For acute gout flares in CKD patients, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to NSAIDs 6
The American College of Rheumatology notes that diet and lifestyle measures alone typically provide only 10-18% decrease in serum urate, which is insufficient for most patients with sustained hyperuricemia above 7 mg/dL 1

Poor adherence to ULT is a common problem in gout patients, and regular monitoring helps address this issue 1
Failure to titrate allopurinol to appropriate doses often leads to suboptimal outcomes, and many patients require doses above 300 mg daily 2
Initiating ULT at high doses increases risk of adverse events, and always starting at low doses and titrating upward is recommended 2
Neglecting prophylaxis against acute flares when initiating ULT can lead to poor medication adherence 9
The American College of Rheumatology notes that diet alone is typically insufficient for adequate urate lowering in most gout patients 1