What diet and treatment options are recommended for a patient with hyperuricemia?

Management of Hyperuricemia: Diet and Treatment Options

For patients with hyperuricemia, a combination of dietary modifications and appropriate medication therapy is recommended, with allopurinol as the first-line medication starting at 100 mg daily and gradually increasing to achieve serum uric acid levels below 6 mg/dL. 1

Dietary Recommendations

Foods to Increase:

• Low-fat dairy products (milk, yogurt) - help lower serum uric acid levels 1
• Vegetable protein as an alternative to animal protein 1
• Cherries - may help reduce frequency of acute gout attacks 1
• Adequate fluid intake - at least 2L of water daily to prevent kidney stone formation 1, 2

Foods to Limit or Avoid:

• Purine-rich foods (>200 mg/100g) should be consumed in limited quantities 3, 4:
  • Seafood (especially anchovy, cutlassfish)
  • Organ meats (especially fish milt)
  • Dried yeast and certain supplements
• Red meat - limit to 5-7 servings per week 1
• Alcohol - especially beer 1
• Sugar-sweetened beverages and fruit juices with high fructose corn syrup 1

General Dietary Principles:

• Gradual weight loss of 5kg if overweight/obese can lower serum uric acid by approximately 1.1 mg/dL 1
• Maintain slightly alkaline urine through diet or supplements to prevent urate crystallization 2
• Avoid strict low-purine diets as they are difficult to maintain and may not provide additional benefits over moderate dietary changes 5

Medication Management

First-Line Therapy:

• Allopurinol:
  • Start at low dose (100 mg daily) 1, 2
  • Increase by 100 mg increments every 2-4 weeks 1, 2
  • Target serum uric acid <6 mg/dL (360 μmol/L) for most patients 1
  • Target <5 mg/dL (300 μmol/L) for severe gout until resolution 1
  • Maintenance dose typically 200-300 mg/day for mild gout, 400-600 mg/day for moderate to severe tophaceous gout 2
  • Maximum recommended dose: 800 mg daily 2

Alternative Medications:

• Febuxostat - when allopurinol is not tolerated 1
• Uricosuric agents (probenecid) - typically 250 mg twice daily for one week, then 500 mg twice daily 6
• Losartan - consider for hypertensive patients with hyperuricemia due to its uricosuric effects 1

Prophylaxis During Initiation:

• Colchicine - provide during early stages of allopurinol therapy to prevent acute gout flares 2
• Anti-inflammatory agents - may be required to suppress gouty attacks during initial therapy 2

Special Considerations

Renal Impairment:

• Adjust medication dosage based on renal function:
  • For creatinine clearance 10-20 mL/min: 200 mg allopurinol daily 2
  • For creatinine clearance <10 mL/min: 100 mg allopurinol daily 2
  • With extreme renal impairment: consider extending interval between doses 2

Medication Cautions:

• Diuretics should be used with caution as they may aggravate hyperuricemia 5, 1
• NSAIDs should be avoided in patients with kidney disease 5
• Low-salt diet is not recommended for patients with certain types of kidney disease as it may aggravate hyperuricemia 5

Monitoring

• Regular serum uric acid testing to ensure target levels are maintained 1
• Monitor renal function especially during early stages of allopurinol therapy 2
• Assess for signs of medication side effects - discontinue allopurinol immediately if rash develops 2

Important Pitfalls to Avoid

• Don't start urate-lowering therapy during an acute attack - wait until it subsides 6
• Don't discontinue allopurinol if gout flares occur during initial therapy - continue medication and treat the acute attack 2
• Don't underestimate the importance of fluid intake - dehydration increases risk of kidney stones 1, 2
• Don't expect immediate results - it may take 2-6 weeks to see benefits from allopurinol therapy 2

By combining appropriate dietary modifications with medication therapy, most patients with hyperuricemia can achieve target uric acid levels and reduce the frequency and severity of gout attacks.