When to treat hyperuricemia (elevated uric acid levels)?

From the Guidelines

Treatment for hyperuricemia should be initiated in patients with symptomatic gout, including those with gout attacks, tophi, or uric acid kidney stones, as well as in patients with asymptomatic hyperuricemia who have a high risk of developing gout or kidney stones, such as those with serum uric acid levels >9 mg/dL, chronic kidney disease (CKD), or urolithiasis. The decision to treat hyperuricemia depends on various factors, including the presence of symptoms, serum uric acid levels, and the risk of developing gout or kidney stones.

• For patients with symptomatic gout, treatment is recommended to reduce the frequency of gout flares and prevent long-term damage to joints and kidneys.
• For patients with asymptomatic hyperuricemia, treatment is generally not recommended unless they have a high risk of developing gout or kidney stones. Some key considerations for treating hyperuricemia include:
• First-line medications: xanthine oxidase inhibitors like allopurinol (starting at 100 mg daily, gradually increasing to 300-600 mg daily) or febuxostat (40-80 mg daily) 1.
• Prophylaxis: colchicine (0.6 mg once or twice daily) or low-dose NSAIDs for 3-6 months to prevent gout flares during initiation of urate-lowering therapy 1.
• Dose adjustment: allopurinol requires dose adjustment in patients with chronic kidney disease, while febuxostat does not 1.
• Alternative treatments: uricosuric agents like probenecid (250-500 mg twice daily) for patients who cannot tolerate xanthine oxidase inhibitors 1.
• Lifestyle modifications: weight loss if overweight, limiting alcohol (especially beer), reducing intake of high-purine foods, and avoiding fructose-rich beverages are important for all patients 1. The treatment goal is to maintain serum uric acid below 6 mg/dL to prevent crystal formation and dissolution of existing deposits 1. Treatment should be continued indefinitely for patients with symptomatic disease to prevent recurrence 1.

From the FDA Drug Label

The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women. Asymptomatic hyperuricemia is not an indication for treatment with allopurinol tablets (see INDICATIONS AND USAGE)

Treatment of Hyperuricemia:

• Hyperuricemia should be treated when it is associated with symptoms or conditions such as gout, kidney stones, or when it occurs in the context of certain diseases like leukemia, polycythemia vera, or psoriasis.
• Asymptomatic hyperuricemia is not an indication for treatment.
• The decision to treat hyperuricemia should be based on the presence of symptoms or the risk of developing complications such as kidney damage or gouty arthritis.
• The target serum uric acid level is below the saturation point, which is around 6-7 mg/dL for most adults, to prevent urate precipitation and deposition in tissues. 2 2

From the Research

Treatment of Hyperuricemia

The treatment of hyperuricemia, or elevated uric acid levels, is a complex issue with various approaches depending on the presence of symptoms and other factors.

• Treatment is generally recommended for symptomatic hyperuricemia, such as gout or urate-nephrolithiasis 3, 4, 5, 6.
• For asymptomatic hyperuricemia, the decision to treat is less clear-cut and may depend on various factors, including the presence of urate crystals in the urine sediment, signs of asymptomatic articular damage, and trends in creatinine, proteinuria, and serum urate levels 3.
• Several medications are available to treat hyperuricemia, including xanthine oxidase inhibitors, uricosuric medications, and recombinant uricases 4, 5, 7.
• The choice of medication and treatment approach may depend on the individual patient's needs and circumstances, including the presence of kidney disease or other comorbidities 5, 6.

Factors to Consider in Treatment

Several factors should be considered when deciding whether to treat hyperuricemia, including:

• The presence of symptoms, such as gout or urate-nephrolithiasis 3, 4, 5, 6.
• The level of serum uric acid and the presence of urate crystals in the urine sediment 3.
• The presence of asymptomatic articular damage, as identified by musculoskeletal ultrasound 3.
• Trends in creatinine, proteinuria, and serum urate levels 3.
• The presence of kidney disease or other comorbidities, which may affect the choice of medication and treatment approach 5, 6.

Medications for Hyperuricemia

Several medications are available to treat hyperuricemia, including:

• Xanthine oxidase inhibitors, such as allopurinol and febuxostat 3, 4, 5.
• Uricosuric medications, such as lesinurad and probenecid 4, 7.
• Recombinant uricases, such as rasburicase 3, 5.
• Other medications, such as canagliflozin, losartan, and fenofibrate, which may have urate-lowering effects 3.