From the Guidelines
Treatment of hyperuricemia should prioritize lifestyle modifications and medications, with xanthine oxidase inhibitors like allopurinol or febuxostat as first-line options, aiming for serum uric acid levels below 6mg/dL. The management of hyperuricemia involves a combination of lifestyle changes and pharmacological interventions. Lifestyle modifications should be the initial approach, including:
- Weight loss if overweight
- Limiting alcohol consumption, especially beer
- Reducing intake of purine-rich foods such as organ meats, seafood, and red meat
- Increasing water intake
For medications, xanthine oxidase inhibitors like allopurinol (starting at 100mg daily and titrating up to 300-600mg daily) or febuxostat (40-80mg daily) are first-line options as they reduce uric acid production 1. Uricosuric agents such as probenecid (250mg twice daily, increasing to 500mg twice daily) increase uric acid excretion through the kidneys. Key considerations in the management of hyperuricemia include:
- The importance of titrating allopurinol dose to achieve target serum uric acid levels, with a starting dose of 100mg daily and increments of 100mg every 2-4 weeks as needed 1
- The potential for allopurinol toxicity, including the rare but potentially life-threatening allopurinol hypersensitivity syndrome (AHS), and the need for careful monitoring and dose adjustment in patients with renal impairment 1
- The role of alternative urate-lowering therapies, such as febuxostat or uricosuric agents, in patients who are intolerant of or have contraindications to allopurinol 1
- The importance of ongoing management and monitoring to prevent complications like gout, kidney stones, and kidney damage, with treatment targets typically aiming for serum uric acid levels below 6mg/dL, though lower targets may be needed for patients with tophi 1.
From the FDA Drug Label
Allopurinol acts on purine catabolism, without disrupting the biosynthesis of purines. It reduces the production of uric acid by inhibiting the biochemical reactions immediately preceding its formation. Hyperuricemia may be primary, as in gout, or secondary to diseases such as acute and chronic leukemia, polycythemia vera, multiple myeloma, and psoriasis The correct size and frequency of dosage for maintaining the serum uric acid just within the normal range is best determined by using the serum uric acid level as an index.
The treatment options for hyperuricemia include allopurinol, which reduces the production of uric acid by inhibiting xanthine oxidase. The dosage of allopurinol should be adjusted based on the serum uric acid level, with the goal of maintaining it within the normal range.
- The recommended dosage for adults is 200-300 mg/day, which may be adjusted up or down depending on the resultant control of hyperuricosuria.
- For children, the recommended dosage is 300 mg/day for those 6-10 years old, and 150 mg/day for those under 6 years old. 2 2
From the Research
Treatment Options for Hyperuricemia
The treatment options for hyperuricemia, a condition characterized by elevated levels of uric acid in the blood, can be divided into two main categories: lifestyle modifications and pharmacological interventions.
Lifestyle Modifications
Lifestyle modifications play a crucial role in managing hyperuricemia and preventing gout attacks. These modifications include:
- Weight reduction through daily exercise and a balanced diet 3
- Limiting intake of red meat and sugary beverages 3
- Avoiding heavy drinking 3
- Increasing consumption of dairy products, vegetables, nuts, legumes, fruits, and whole grains 3, 4
- Following a Mediterranean or Dietary Approaches to Stop Hypertension (DASH) diet, which have been shown to have beneficial effects on cardiometabolic health and gout endpoints 4
Pharmacological Interventions
Pharmacological interventions for hyperuricemia and gout include:
- Colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids for relieving pain during acute gout episodes 5, 6, 7
- Urate-lowering therapies, such as allopurinol and febuxostat, to prevent gout flares 5, 6, 7
- Uricosuric agents, such as probenecid, sulfinpyrazone, and benzbromarone, as adjuncts to urate-lowering therapies 7
- Novel therapies, such as pegloticase, for patients with recalcitrant gout 6
- IL-1 inhibitors for flare refractory to standard therapies 7
Considerations for Treatment
When selecting a treatment option, it is essential to consider the individual patient's characteristics, such as comorbidities, including chronic kidney disease and ischemic heart disease, as well as patient preference 7. Additionally, screening for HLA*B58:01 mutation is recommended for certain populations, such as Southeast Asian and Black populations, to decrease the occurrence of allopurinol hypersensitivity syndrome 6.