How to manage elevated Serum Uric Acid (SUA) levels?

Management of Elevated Serum Uric Acid (SUA) Levels

Management of elevated serum uric acid (SUA) should include lifestyle modifications, addressing comorbidities, and urate-lowering therapy (ULT) with a target SUA level of <6 mg/dL (360 μmol/L) maintained lifelong for patients with gout.

Initial Assessment and Lifestyle Modifications

• Every person with elevated SUA should receive comprehensive education about the pathophysiology of hyperuricemia, treatment options, and the importance of lifelong management 1
• Weight loss should be recommended for overweight patients, as successful weight reduction can lower SUA levels from 570 μmol/L to 470 μmol/L within 16 weeks 1
• Dietary modifications should include:
  • Reducing intake of purine-rich foods (meat and seafood) 1
  • Limiting alcohol consumption, especially beer and spirits 1
  • Avoiding sugar-sweetened drinks and foods rich in fructose 1
  • Encouraging consumption of low-fat dairy products, which have an inverse association with SUA levels 1
  • Including coffee and cherries, which may have beneficial effects on SUA levels 1, 2

Addressing Comorbidities

• Screen for and manage associated conditions including hyperlipidemia, hypertension, hyperglycemia, obesity, and cardiovascular disease 1
• Consider medication adjustments for patients with hypertension or hyperlipidemia:
  • For hypertension, consider losartan which has uricosuric effects 1
  • For hyperlipidemia, consider fenofibrate which can reduce SUA levels 1
  • If possible, substitute loop or thiazide diuretics which can increase SUA levels 1

Urate-Lowering Therapy (ULT)

When to Initiate ULT:

• ULT should be considered and discussed with every patient with a definite diagnosis of gout from first presentation 1
• ULT is strongly indicated for patients with:
  • Recurrent gout flares 1
  • Tophi 1
  • Urate arthropathy or renal stones 1
  • Young age (<40 years) at presentation 1
  • Very high SUA levels (>8.0 mg/dL; 480 μmol/L) 1, 3
  • Comorbidities (renal impairment, hypertension, heart disease) 1

First-Line ULT:

• Allopurinol is the recommended first-line therapy for patients with normal kidney function 1, 4
  • Start at a low dose (100 mg/day) and increase by 100 mg increments every 2-4 weeks until reaching target SUA 1, 4
  • Dosage range is typically 200-300 mg/day for mild gout and 400-600 mg/day for moderately severe tophaceous gout 4
  • Maximum approved dose is 800 mg/day 5, 4
  • In renal impairment, adjust maximum dosage according to creatinine clearance 1, 4

Alternative ULT Options:

• If allopurinol target cannot be reached or is not tolerated, consider:
  • Febuxostat 1
  • Uricosuric agents like probenecid 1, 6
  • Combination therapy of allopurinol with a uricosuric agent 1

Monitoring and Maintenance

• Target SUA level should be <6 mg/dL (360 μmol/L) for most patients 1, 5
• For patients with severe gout (tophi, chronic arthropathy, frequent attacks), consider a lower target of <5 mg/dL (300 μmol/L) until resolution 1, 3
• Monitor SUA levels every 6 months once stable 5
• ULT should be maintained lifelong as discontinuation leads to recurrence in approximately 87% of patients within 5 years 1, 5

Flare Prophylaxis

• Prophylaxis against flares is recommended during the first 6 months of ULT 1
• Recommended prophylactic treatment is colchicine 0.5-1 mg/day, with dose reduction in renal impairment 1
• If colchicine is contraindicated or not tolerated, low-dose NSAIDs can be considered if not contraindicated 1

Common Pitfalls to Avoid

• Discontinuing ULT after achieving symptom control, which leads to recurrence of gout flares 5
• Relying solely on the standard 300mg allopurinol dose, which fails to achieve target urate levels in many patients 5
• Neglecting to address comorbidities and cardiovascular risk factors 1, 7
• Failing to provide adequate flare prophylaxis when initiating ULT 1