Indications for Uric Acid Lowering Therapy in Gout
Primary Recommendation
Urate-lowering therapy (ULT) should be considered and discussed with every patient from the first presentation of definite gout, and is definitively indicated in patients with recurrent flares, tophi, urate arthropathy, radiographic changes, or renal stones. 1
Absolute Indications for ULT
ULT is mandatory in the following clinical scenarios:
- Recurrent acute gout attacks (≥2 attacks per year) 1
- Presence of tophi (subcutaneous or intra-articular) 1
- Chronic gouty arthropathy or joint damage 1
- Radiographic changes of gout (erosions, joint space narrowing) 1
- Uric acid nephrolithiasis or kidney stones 1
Strong Indications for Early ULT Initiation
ULT initiation is strongly recommended close to the time of first diagnosis in patients with:
- Young age at presentation (<40 years) 1
- Very high serum uric acid levels (>8.0 mg/dL or 480 μmol/L) 1
- Significant comorbidities including renal impairment, hypertension, ischemic heart disease, or heart failure 1
Treatment Target
The therapeutic goal is to maintain serum uric acid below 6 mg/dL (360 μmol/L) to prevent crystal formation and promote crystal dissolution. 1, 2
For patients with severe gout (tophi, chronic arthropathy, frequent attacks), target a lower level of <5 mg/dL (300 μmol/L) to facilitate faster crystal dissolution until complete resolution. 1, 2
Avoid long-term maintenance of serum uric acid <3 mg/dL. 1
Refractory Gout Indication
Pegloticase is indicated for crystal-proven, severe debilitating chronic tophaceous gout with poor quality of life when the serum uric acid target cannot be reached with any other available drug at maximal dosage (including combinations). 1, 3
Critical Monitoring Requirements
- Monitor serum uric acid levels prior to each infusion when using pegloticase 3
- Consider discontinuing treatment if levels increase above 6 mg/dL, particularly when 2 consecutive levels above 6 mg/dL are observed 3
- The risk of anaphylaxis and infusion reactions is higher in patients who have lost therapeutic response 3
Important Limitation
ULT is NOT recommended for asymptomatic hyperuricemia without a diagnosis of gout. 3
Common Pitfalls to Avoid
Discontinuing ULT after symptom improvement leads to recurrence of gout flares in approximately 87% of patients within 5 years. Lifelong maintenance of serum uric acid below target levels is required to prevent crystal reformation. 2
Patients must receive flare prophylaxis (colchicine 0.5-1 mg/day or low-dose NSAID) during the first 6 months of ULT to prevent acute attacks triggered by crystal mobilization. 1, 2