From the Guidelines
Asymptomatic hyperuricemia does not require treatment with urate-lowering therapy, and patients should focus on lifestyle modifications instead. According to the 2020 American College of Rheumatology guideline for the management of gout 1, initiating urate-lowering therapy (ULT) is conditionally recommended against in patients with asymptomatic hyperuricemia. The guideline suggests that the benefits of ULT would not outweigh potential treatment costs or risks for the large number of patients unlikely to progress to gout.
Key Considerations
- The development of incident gout was low for both ULT and placebo arms (<1% versus 5%) in randomized controlled trials (RCTs) designed to study cardiovascular disease outcomes 1.
- Among patients with asymptomatic hyperuricemia with serum uric acid concentrations of >9 mg/dl, only 20% went on to develop gout within 5 years 1.
- Lifestyle modifications, such as maintaining a healthy weight, limiting alcohol consumption, reducing intake of purine-rich foods, avoiding high-fructose corn syrup, and staying well-hydrated, are recommended for patients with asymptomatic hyperuricemia 1.
- Regular monitoring of uric acid levels is recommended, typically every 6-12 months.
Treatment Exceptions
- Treatment with medications such as allopurinol or febuxostat should be considered only in specific circumstances, such as extremely high uric acid levels (>13 mg/dL), presence of uric acid kidney stones, or certain conditions that significantly increase risk of gout.
- Patients with comorbid moderate-to-severe chronic kidney disease (CKD), serum uric acid concentration >9 mg/dl, or urolithiasis may benefit from ULT, but this should be decided on a case-by-case basis 1.
From the FDA Drug Label
Asymptomatic hyperuricemia is not an indication for treatment with allopurinol tablets (see INDICATIONS AND USAGE) The FDA drug label does not support the use of allopurinol for asymptomatic hyperuricemia.
- The label explicitly states that asymptomatic hyperuricemia is not an indication for treatment with allopurinol tablets 2.
From the Research
Asymptomatic Hyperuricemia: Treatment and Management
- Asymptomatic hyperuricemia is associated with increased cardiovascular risk, and treatment is controversial due to possible side effects of urate-lowering drugs 3.
- A network meta-analysis found that benzbromarone and allopurinol had the best efficacy in lowering serum uric acid levels in short-term and long-term follow-up 3.
- Allopurinol was found to have a renoprotective effect, and febuxostat had a significant impact on lowering diastolic blood pressure 3.
- Urate-lowering therapy does not result in a higher risk of safety events 3.
Urate-Lowering Therapies
- Febuxostat was found to have superior urate-lowering efficacy compared to allopurinol in Chinese patients with hyperuricemia and chronic kidney disease stages 3-5 4.
- The reduction in serum uric acid levels was associated with a slower progression of renal function 4.
- Allopurinol is often prescribed for asymptomatic hyperuricemia despite lacking conclusive evidence from prospective randomized controlled trials 5.
Management and Treatment Approaches
- There is no unified answer to the question of whether urate-lowering therapy is necessary in asymptomatic hyperuricemia 6.
- The use of direct-acting urate-lowering agents in asymptomatic hyperuricemia associated with cardiovascular diseases does not warrant a clear benefit 7.
- Addressing cardiovascular issues with guideline-recommended therapies can lower uric acid and reduce the occurrence of cardiovascular events 7.
- Regular assessment of uric acid and clinical symptoms is advised before starting and renewing urate-lowering treatment 7.