From the Guidelines
If your uric acid level remains at 7.0 mg/dL despite taking allopurinol 600mg daily, you should discuss with your doctor about switching to febuxostat or adding a uricosuric to your current allopurinol regimen, as the target uric acid level is below 6.0 mg/dL, according to the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
Treatment Options
When uric acid levels remain elevated despite allopurinol treatment, several options can be considered:
- Switching to febuxostat, which is a more potent urate-lowering therapy, as recommended by the EULAR guidelines 1
- Adding a uricosuric, such as probenecid, to the current allopurinol regimen, to increase uric acid excretion through the kidneys
- Checking adherence to the current allopurinol regimen, as inconsistent use can reduce its effectiveness
- Investigating potential interfering factors, such as certain diuretics, low-dose aspirin, or alcohol consumption, that can reduce allopurinol's effectiveness
Lifestyle Modifications
In addition to medication adjustments, lifestyle modifications can complement therapy:
- Reducing intake of high-purine foods, such as organ meats and shellfish
- Limiting alcohol consumption
- Maintaining adequate hydration
- Weight loss, if applicable, to help lower uric acid levels
Monitoring and Adjustments
Regular monitoring of uric acid levels and kidney function is essential to adjust treatment as needed, as recommended by the EULAR guidelines 1. The goal is to maintain a uric acid level below 6.0 mg/dL, and sometimes below 5.0 mg/dL for patients with severe disease.
From the FDA Drug Label
The degree of this decrease can be manipulated almost at will since it is dose-dependent A week or more of treatment with allopurinol tablets may be required before its full effects are manifested; Allopurinol tablets can substantially reduce serum and urinary uric acid levels in previously refractory patients even in the presence of renal damage serious enough to render uricosuric drugs virtually ineffective
The patient's uric acid level is still 7.0 after taking allopurinol 600mg daily. Dose adjustment may be necessary to achieve the desired reduction in uric acid levels. It is also possible that the patient may require additional time to respond to the treatment, as the full effects of allopurinol may not be manifested until after a week or more of treatment. Alternatively, combination therapy with a uricosuric agent may be considered to enhance the reduction of uric acid levels, but this should be done with caution and careful monitoring of the patient's renal function 2.
From the Research
Treatment Options for Hyperuricemia
When uric acid levels remain high (7.0 mg/dL) despite taking allopurinol 600mg daily, several alternative treatment options can be considered:
- Increasing the dose of allopurinol, although this may increase the risk of adverse effects
- Switching to febuxostat, a non-purine selective xanthine oxidase inhibitor, which has been shown to be effective in reducing serum uric acid levels 3, 4
- Adding other urate-lowering therapies, such as uricosurics or uricase inhibitors, although these may have limited efficacy and potential side effects
Febuxostat as an Alternative Treatment
Febuxostat has been shown to be effective in reducing serum uric acid levels, particularly in patients with chronic kidney disease (CKD) and hyperuricemia 3, 4. The long-term use of febuxostat may also exert a protective effect on the kidneys 3. However, it is essential to monitor patients for potential adverse effects, such as liver enzyme elevations and cardiovascular events.
Considerations for Asymptomatic Hyperuricemia
In patients with asymptomatic hyperuricemia, the decision to treat should be based on individual risk factors and clinical assessment 5. Regular monitoring of uric acid levels and clinical symptoms is recommended before starting and renewing urate-lowering treatment. Addressing cardiovascular issues with guideline-recommended therapies may also help lower uric acid levels and reduce the occurrence of cardiovascular events.
Xanthine Oxidase Inhibitors as a Treatment Option
Xanthine oxidase inhibitors, such as allopurinol and febuxostat, remain the first choice of urate-lowering drug for chronic treatment due to their efficacy, safety, and relatively low cost 6. These medications have been shown to be effective in reducing serum uric acid levels and may also have positive effects on vascular health, renal function, and glucose metabolism.