Management of Elevated CRP and Hyperuricemia
Diagnostic Evaluation
- The American College of Rheumatology recommends considering potential causes of hyperuricemia and elevated CRP for all patients, including assessment of comorbidities such as hypertension, heart failure, hyperlipidemia, and organ transplant status 1, 2
- Evaluate for medications that may elevate serum urate levels, including thiazide and loop diuretics, niacin, and calcineurin inhibitors, as suggested by the American College of Rheumatology 1, 2
- For patients with hyperuricemia and elevated CRP, perform a thorough clinical evaluation including history and physical examination for symptoms of arthritis and signs such as tophi and synovitis, according to the American College of Rheumatology 1
- Consider screening for uric acid overproduction (via urine uric acid evaluation) in patients with early-onset hyperuricemia (before age 25) or history of urolithiasis, as recommended by the American College of Rheumatology 1
Non-Pharmacologic Management
- Implement diet and lifestyle modifications as foundational treatment for all patients with hyperuricemia and elevated CRP, including limiting consumption of purine-rich meat and seafood, reducing consumption of high fructose corn syrup-sweetened beverages, encouraging consumption of low-fat or non-fat dairy products, reducing alcohol consumption, and complete abstinence from alcohol during periods of active arthritis, as suggested by the European League Against Rheumatism 3, 4, 5
- Recognize that diet and lifestyle measures alone typically provide insufficient serum urate-lowering effects (only ~10-18% decrease in serum urate) for many patients, according to the European League Against Rheumatism 5
Pharmacologic Management
- Initiate urate-lowering therapy (ULT) when clinically indicated, with the goal of achieving serum urate below 6 mg/dL at minimum, as recommended by the American College of Rheumatology 6, 7
- For patients with greater disease severity (tophi or chronic tophaceous gouty arthropathy), target serum urate below 5 mg/dL, according to the American College of Rheumatology 6, 7
- First-line ULT options include Allopurinol, Febuxostat, and Probenecid, as suggested by the American College of Rheumatology 7
- For refractory cases, consider combination therapy with XOI plus uricosuric agents (probenecid, fenofibrate, or losartan), or Pegloticase as a third-line agent, according to the American College of Rheumatology 7
Special Considerations
- Address the underlying cause of inflammation, as recommended by the American Heart Association 8
- For highly elevated CRP (>10 mg/L), evaluate for non-cardiovascular causes of inflammation, according to the American Heart Association 8
Referral Considerations
- Consider referral to a specialist in cases with unclear etiology of hyperuricemia, refractory signs or symptoms of gout, difficulty achieving target serum urate level, or multiple or serious adverse events from pharmacologic ULT, as suggested by the American College of Rheumatology 1, 2, 5