What is the recommended treatment for hyperuricemia?

Management of Hyperuricemia with Uric Acid Level of 13.8 mg/dL

Allopurinol should be initiated as first-line urate-lowering therapy (ULT) with a starting dose of 100 mg/day, followed by gradual dose titration to achieve a serum urate target of <6 mg/dL. 1

Indications for Treatment

A uric acid level of 13.8 mg/dL represents severe hyperuricemia that requires pharmacologic intervention due to:

• High risk of gout progression and tophus formation
• Increased risk of gout flares
• Potential kidney damage from urate crystal deposition
• Markedly elevated serum urate (>9 mg/dL) which is associated with disease progression 1

Treatment Algorithm

First-Line Therapy

• Allopurinol:
  • Start at 100 mg/day (or 50 mg/day if CKD stage 4 or worse) 1, 2
  • Gradually increase dose by 100 mg every 2-5 weeks 1
  • Titrate to achieve serum urate <6 mg/dL 2
  • Maximum FDA-approved dose is 800 mg/day 2

Monitoring During Therapy

• Check serum urate levels every 2-5 weeks during dose titration 1
• Monitor for adverse effects (rash, pruritus, elevated liver enzymes) 1
• Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD stage 3+, Han Chinese, Thai) 1
• Maintain fluid intake of at least 2 liters daily 2
• Aim for slightly alkaline urine 2

Alternative/Second-Line Options

If allopurinol is not tolerated or ineffective:

• Febuxostat can be substituted for allopurinol 1
• Combination therapy may be considered for refractory cases:
  • Addition of a uricosuric agent (probenecid, fenofibrate, losartan) to allopurinol 1
• Pegloticase for severe, refractory cases with high disease burden 1

Special Considerations

Renal Impairment

• Allopurinol dose adjustment based on creatinine clearance:
  • 10-20 mL/min: 200 mg/day
  • <10 mL/min: ≤100 mg/day 2
• Probenecid is not recommended as first-line therapy if creatinine clearance <50 mL/min 1

Flare Prophylaxis

• Continue colchicine and/or anti-inflammatory agents until serum uric acid has been normalized and patient has been free from acute gout attacks for several months 2

Dietary and Lifestyle Modifications

• Limit high-purine foods (meat, seafood) 3
• Reduce alcohol consumption, especially beer and spirits 3
• Avoid sugar-sweetened beverages (high fructose) 3
• Increase fluid intake 3, 2
• Consider potassium citrate for urine alkalinization 1, 3

Important Caveats

• Allopurinol is not recommended for asymptomatic hyperuricemia without gout or other indications 2
• However, with a uric acid level of 13.8 mg/dL, the risk of developing gout and complications is significantly increased
• Rapid lowering of uric acid can paradoxically trigger gout flares; use prophylactic anti-inflammatory therapy during initiation 2
• When transferring from a uricosuric agent to allopurinol, gradually reduce the uricosuric dose while increasing allopurinol 2
• Allopurinol is better tolerated when taken after meals 2

Contraindications to Uricosuric Therapy

• History of urolithiasis 1
• Elevated urine uric acid (overproduction) 1
• Creatinine clearance <50 mL/min 1

By following this treatment approach, the goal is to effectively lower serum urate levels, prevent gout attacks, reduce tophus formation, and minimize the risk of complications associated with hyperuricemia.