How to manage elevated uric acid levels in patients with Rheumatoid Arthritis (RA)?

From the Guidelines

Managing elevated uric acid levels in patients with rheumatoid arthritis requires a targeted approach that addresses both conditions simultaneously, with first-line treatment typically involving urate-lowering therapy with allopurinol, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. The goal of treatment is to maintain serum uric acid (SUA) levels at <6 mg/dL (360 mmol/L) and <5 mg/dL (300 mmol/L) in those with severe gout, while also considering the potential effects of rheumatoid arthritis medications on uric acid levels.

• Key considerations in managing elevated uric acid levels in patients with rheumatoid arthritis include:
  • Starting urate-lowering therapy with allopurinol at a low dose (100 mg/day) and increasing by 100 mg increments every 2–4 weeks if required, to reach the uricaemic target 1
  • Using febuxostat (40-80mg daily) as an alternative for patients who cannot tolerate allopurinol 1
  • Considering colchicine (0.6mg once or twice daily) for 3-6 months to prevent gout flares during initiation of urate-lowering therapy 1
  • Monitoring SUA levels regularly, every 2-3 months until target levels are achieved, and then every 6-12 months thereafter 1
  • Maintaining a treat-to-target strategy to keep SUA levels <6 mg/dL, and <5 mg/dL for patients with severe gout, to facilitate faster dissolution of crystals and prevent new formation of urate crystals 1 Some studies have suggested that uric acid might have protective effects against neurodegenerative diseases, but the task force does not recommend lowering SUA levels to <3 mg/dL in the long term 1.
• Dietary modifications, such as limiting purine-rich foods, reducing alcohol, avoiding high-fructose corn syrup, and maintaining adequate hydration, are also beneficial in managing elevated uric acid levels in patients with rheumatoid arthritis. It is essential to consider the potential interactions between urate-lowering therapy and rheumatoid arthritis medications, as well as the patient's kidney function, when managing elevated uric acid levels in patients with rheumatoid arthritis 1.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The minimal effective dosage is 100 to 200 mg daily and the maximal recommended dosage is 800 mg daily To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage.

Managing Elevated Uric Acid Levels in Patients with Rheumatoid Arthritis (RA):

• The goal is to reduce serum uric acid levels to normal or near-normal levels.
• Allopurinol can be used to manage elevated uric acid levels, with a starting dose of 100 mg daily and gradual increases until a serum uric acid level of 6 mg/dL or less is attained.
• The dosage may need to be adjusted based on the patient's response and serum uric acid levels.
• It is essential to monitor serum uric acid levels and adjust the dosage accordingly to maintain levels within the normal range.
• Probenecid may also be used, but its effectiveness may be limited in patients with chronic renal insufficiency.
• A liberal fluid intake and alkalization of the urine may also be recommended to help manage uric acid levels 2, 3.

From the Research

Managing Elevated Uric Acid Levels in Patients with Rheumatoid Arthritis (RA)

To manage elevated uric acid levels in patients with Rheumatoid Arthritis (RA), several approaches can be considered:

• Medications: Allopurinol is an effective treatment for reducing concentrations of uric acid, as stated in 4. The starting dose of allopurinol should be guided by renal function, and the maintenance dose should be guided by the baseline serum uric acid concentration. Febuxostat is another xanthine oxidase inhibitor that is clinically equivalent to allopurinol.
• Lifestyle Changes: Weight reduction through daily exercise and limiting intake of excess calories is recommended, as obesity increases uric acid and weight gain increases gout risk 5. Additionally, a Mediterranean diet may help prevent hyperuricemia, and coffee and vitamin C supplementation could be considered as preventive measures.
• Monitoring and Education: Regular serum urate monitoring and improved patient education can help achieve better gout-related outcomes, as discussed in 6. Interventions such as initiation of prophylactic anti-inflammatory medication when starting urate-lowering therapy, frequent follow-ups, and pharmacist- or nurse-assisted programs can also improve adherence to urate-lowering therapy.

Considerations for RA Patients

For patients with RA, it is essential to consider the potential relationship between uric acid levels and renal dysfunction. Uric acid is a strong independent predictor of renal dysfunction in patients with RA, as shown in 7. Therefore, RA patients with elevated uric acid may require screening for renal dysfunction and appropriate management. Furthermore, the potential protective effect of hyperuricemia against rheumatoid inflammation should be taken into account, as suggested in 8.