From the Guidelines
Gout can occur even with normal uric acid levels, and diagnosis should be based on clinical judgment and synovial fluid analysis, as recommended by the American College of Physicians 1. To diagnose gout with normal uric acid, joint aspiration and crystal analysis remain the gold standard, as the presence of monosodium urate crystals confirms gout regardless of serum uric acid levels. The following key points are essential in managing gout with normal uric acid levels:
- Treatment for normouricemic gout follows standard gout protocols:
- NSAIDs like indomethacin (50mg three times daily for 3-5 days)
- Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve)
- Or corticosteroids for acute attacks, as recommended by the European League Against Rheumatism (EULAR) 1
- For long-term management, urate-lowering therapy such as allopurinol (starting at 100mg daily and titrating up) may still be appropriate for patients with recurrent attacks, even with normal uric acid levels 1
- Lifestyle modifications including weight loss, limiting alcohol (especially beer), reducing intake of high-purine foods like red meat and seafood, and staying well-hydrated are also important, as they can help reduce the risk of gout attacks and improve overall health 1 Patients should understand that a normal uric acid level during an attack doesn't rule out gout, and repeated measurements between attacks may reveal previously undetected hyperuricemia. It is crucial to note that the management of gout with normal uric acid levels should prioritize the patient's quality of life, morbidity, and mortality, and treatment decisions should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.
From the FDA Drug Label
The etiology of this hyperuricemia is the overproduction of uric acid in relation to the patient's ability to excrete it Gout is a metabolic disorder which is characterized by hyperuricemia and resultant deposition of monosodium urate in the tissues, particularly the joints and kidneys. Normal serum urate levels are usually achieved in 1 to 3 weeks The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women.
Gout with normal uric acid is not directly addressed in the provided drug labels. The labels discuss the treatment of gout and hyperuricemia with allopurinol, but do not provide information on the management of gout when uric acid levels are normal.
- The labels do provide information on the normal range for serum urate levels, which is below 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women.
- However, the labels do not discuss the specific scenario of gout with normal uric acid levels.
- Therefore, no conclusion can be drawn regarding the management of gout with normal uric acid levels based on the provided drug labels 2, 2, 2.
From the Research
Gout with Normal Uric Acid Levels
- Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within synovium of joints 3.
- The diagnosis of gout can be made using several validated clinical prediction rules, and arthrocentesis should be performed when suspicion for an underlying septic joint is present 4.
- A study found that 63.3% of patients with acute gout attack had normal serum uric acid levels, and the diagnosis of acute gout attack should not be excluded in the presence of normal serum uric acid levels if the clinical manifestations or the positive response to colchicine are suggestive of gout 5.
Treatment Options
- Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes 4.
- Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 4.
- Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended 4.
Special Considerations
- The low uric acid level is correlated with increased inflammatory factors and urinary excretion of uric acid 5.
- In Southeast Asian and Black populations, screening for HLA*B58:01 mutation is a cost-effective approach to decrease the occurrence of allopurinol hypersensitivity syndrome 6.
- Novel uricosurics are a class for continued drug development, and verinurad and arhalofenate are agents with future promise 6.