Should a 69-year-old patient with a history of gout, currently on allopurinol (Allopurinol) 100 mg daily, continue or discontinue therapy given a serum uric acid level of 5.9 mg/dL, indicating hyperuricemia?

From the Guidelines

The patient should continue allopurinol 100 mg daily, as the current serum uric acid level of 5.9 mg/dL is close to the target range of <6 mg/dL, and discontinuing therapy may lead to rising uric acid levels and potentially trigger gout flares. The 2016 updated EULAR evidence-based recommendations for the management of gout suggest that allopurinol is recommended for first-line urate-lowering therapy (ULT), starting 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. For patients on ULT, serum uric acid (SUA) level should be monitored and maintained to <6 mg/dL (360mmol/L) to prevent recurrent attacks, joint damage, and tophi formation.

• Key points to consider in this patient's management include:
  • The importance of maintaining a SUA level <6 mg/dL to prevent gout flares and joint damage
  • The need for regular monitoring of uric acid levels and kidney function while on allopurinol therapy
  • The potential for allopurinol to be effective in reducing uric acid levels and preventing gout flares, as supported by studies showing its superior urate-lowering efficacy over placebo 1
  • The recommendation to start ULT early, particularly in patients with comorbidities and/or SUA level >8 mg/dL, and to involve the patient in the decision-making process to ensure adherence to ULT and optimal patient-centred outcomes 1. Given the patient's current serum uric acid level and the lack of any reported side effects, continuing allopurinol 100 mg daily is the most appropriate course of action, as it is effectively controlling uric acid levels and reducing the risk of gout flares, in line with the recommendations from the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

From the FDA Drug Label

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. The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women. The correct size and frequency of dosage for maintaining the serum uric acid just within the normal range is best determined by using the serum uric acid level as an index.

The patient's serum uric acid level is 5.9 mg/dL, which is below the target level of 6 mg/dL.

• The patient is currently on a daily dose of 100 mg, which is within the recommended minimal effective dosage range.
• Continuation of therapy is recommended as the serum uric acid level is already within the target range, and the patient has a history of gout.
• No dose adjustment is necessary at this time, as the current dose is effective in maintaining a serum uric acid level below 6 mg/dL 2.

From the Research

Patient's Current Condition

• The patient is 69 years old with a history of gout and is currently on allopurinol 100 mg daily.
• The patient's serum uric acid level is 5.9 mg/dL, indicating hyperuricemia.

Allopurinol Therapy

• According to 3, allopurinol is the most commonly used hypouricaemic agent, but at recommended doses, it often fails to reduce adequately uric acid concentrations and prevent acute attacks of gout.
• 4 suggests that low-dose allopurinol may promote greater serum urate lowering in gout patients with chronic kidney disease compared to those with normal kidney function.
• 5 found that allopurinol monotherapy (200-300 mg/day) was less effective in attaining target serum urate levels compared to benzbromarone, but the addition of probenecid to allopurinol proved to be an effective treatment strategy.

Dosing Considerations

• 6 recommends gradual introduction of allopurinol according to current treatment guidelines, with close monitoring of serum uric acid concentrations, and considers allopurinol dose escalation above recommended guidelines in patients with severe disease and persistent hyperuricemia.
• 7 suggests that the initial dosage of allopurinol should be low, particularly in patients with renal impairment, and that the dose should be increased slowly until plasma concentrations of urate are sufficient to dissolve monosodium urate crystals.

Decision to Continue or Discontinue Therapy

• Based on the patient's serum uric acid level of 5.9 mg/dL, indicating hyperuricemia, and considering the studies mentioned above, it may be necessary to reassess the patient's allopurinol dosage to achieve optimal urate lowering.
• The decision to continue or discontinue allopurinol therapy should be made on a case-by-case basis, taking into account the patient's individual response to treatment, renal function, and other medical conditions, as well as the potential risks and benefits of therapy, as discussed in 3, 4, 5, 6, 7.