Initiating Uric Acid Lowering Therapy in Hyperuricemia

Strong Indications for Starting ULT

• The American College of Rheumatology recommends ULT for patients with one or more subcutaneous tophi, as it is strongly indicated for this population 1, 4
• ULT is strongly recommended when there is radiographic damage attributable to gout, as evidenced by studies 1, 4
• Patients experiencing ≥2 gout flares per year should be started on ULT, according to guidelines 1, 4

Conditional Indications for Starting ULT

• The American College of Rheumatology conditionally recommends ULT for patients who have experienced >1 flare but have infrequent flares (<2/year) 2, 4
• ULT is conditionally recommended for patients experiencing their first flare with high-risk features, such as chronic kidney disease (CKD) stage ≥3 1, 5
• Patients with serum urate >9 mg/dL or a history of urolithiasis should be considered for ULT, as per guidelines 1, 4

Asymptomatic Hyperuricemia

• The American College of Rheumatology recommends against ULT for patients with asymptomatic hyperuricemia (SU >6.8 mg/dL with no prior gout flares or tophi), except in specific cases 1, 4
• Clinical trials show that only 20% of patients with asymptomatic hyperuricemia with SU >9 mg/dL develop gout within 5 years, making treatment unnecessary for most patients 4, 6

Special Considerations for CKD Patients

• ULT is recommended for people with CKD and symptomatic hyperuricemia, according to the American Journal of Kidney Diseases 5, 7
• Consider initiating ULT after the first gout episode in adults with CKD, particularly with no avoidable precipitant or serum uric acid >9 mg/dL 5, 7
• Xanthine oxidase inhibitors, such as allopurinol, are preferred over uricosuric agents in people with CKD and symptomatic hyperuricemia 5, 7

Treatment Considerations

• All ULTs should be started at a low dose and then titrated upward until the SU target is reached, as recommended by the Annals of the Rheumatic Diseases 8
• Serum urate should be maintained at <6 mg/dL (360 μmol/L) long-term, with lower targets (<5 mg/dL; 300 μmol/L) for patients with severe gout 8
• Allopurinol is recommended as the preferred first-line agent, even in patients with moderate-to-severe CKD 4