How to manage a patient with hyperparathyroidism and gout?

Management of Hyperparathyroidism and Gout

Treat the hyperparathyroidism definitively with parathyroidectomy if indicated, as this will simultaneously improve the hyperuricemia and reduce gout burden, while managing acute gout flares with colchicine or corticosteroids and initiating early urate-lowering therapy given the high-risk comorbidity profile.

Understanding the Pathophysiologic Link

The association between hyperparathyroidism and gout is well-established, with patients having a 3-fold increased risk of hyperparathyroidism compared to those without calcium pyrophosphate deposition disease 1. The mechanism involves:

• Reduced tubular secretion of urate due to hypoperfusion of the renal capillary network, which is the primary driver of hyperuricemia in hyperparathyroidism 2
• Decreased urate clearance without changes in filtered urate or presecretory reabsorption 2
• Parathyroidectomy significantly reduces serum urate levels (from 365.3 to 265.7 μmol/L within 6 months) 3

Immediate Management of Acute Gout Attack

For acute flares, avoid NSAIDs given the likely presence of renal impairment from hyperparathyroidism:

• Colchicine: 1 mg loading dose, then 0.5 mg one hour later 4
• Oral corticosteroids: Prednisolone 30-35 mg/day for 3-5 days if colchicine is contraindicated 4
• Continue any existing urate-lowering therapy during acute attacks—do not stop 4

Definitive Treatment of Hyperparathyroidism

Parathyroidectomy is the priority intervention as it addresses the root cause:

• Surgical removal of parathyroid adenoma reduces serum urate significantly within 48 hours to 6 months 3, 5
• Critical caveat: Obtain preoperative radiographs of knees, wrists, and pelvis to screen for chondrocalcinosis 5
• Prophylaxis required: Give colchicine 1 mg/day orally starting preoperatively to prevent post-parathyroidectomy pseudogout, which occurs within 48 hours of surgery 5
• Post-surgical pseudogout develops due to rapid calcium shifts and crystal mobilization 5

Concurrent Urate-Lowering Therapy Initiation

Do not wait to start urate-lowering therapy—hyperparathyroidism is a high-risk comorbidity mandating early treatment 4:

• Start allopurinol at 100 mg daily, increasing by 100 mg every 2-4 weeks until serum uric acid <6 mg/dL (360 μmol/L) 4, 6
• Maximum dose 800 mg daily, though most patients require 400-600 mg daily for control 6
• Adjust for renal impairment (common in hyperparathyroidism):
  • Creatinine clearance 10-20 mL/min: 200 mg daily maximum 6
  • Creatinine clearance <10 mL/min: 100 mg daily maximum 6
  • Creatinine clearance <3 mL/min: lengthen dosing intervals 6

Mandatory Flare Prophylaxis During ULT Initiation

Prophylaxis is non-negotiable for the first 6 months when starting allopurinol 4, 6:

• Colchicine 0.5-1 mg daily is first-line 4
• Reduce to 0.5 mg daily or every other day if creatinine clearance 30-50 mL/min 4
• Low-dose corticosteroids are alternatives when colchicine is contraindicated 4
• Prophylaxis prevents mobilization flares that occur as urate deposits dissolve 6

Medication Review and Optimization

Review all medications for urate-raising effects 4:

• Discontinue thiazide or loop diuretics if possible, as these are the most common iatrogenic cause of gout 4
• Switch to losartan (modest uricosuric effects) or calcium channel blockers for hypertension 4
• Consider fenofibrate for hyperlipidemia (has uricosuric properties) 4

Lifestyle Modifications

Every patient requires comprehensive lifestyle counseling 4:

• Weight loss if obese 4
• Eliminate alcohol, especially beer and spirits 4
• Avoid sugar-sweetened drinks and high-fructose foods 4
• Reduce red meat and seafood intake 4
• Encourage low-fat dairy products, particularly skim milk 4
• Maintain fluid intake sufficient for at least 2 liters daily urinary output 6
• Maintain neutral or slightly alkaline urine to prevent xanthine calculi formation 6

Monitoring Strategy

Target serum uric acid <6 mg/dL lifelong 4:

• Check serum urate levels every 2-4 weeks during dose titration 6
• Monitor renal function closely during early allopurinol therapy, as renal impairment may worsen 6
• Assess for bone marrow depression (rare but can occur 6 weeks to 6 years after starting allopurinol) 6

Critical Pitfalls to Avoid

• Do not stop urate-lowering therapy during acute flares—this perpetuates the cycle of recurrent attacks 4
• Do not start allopurinol at high doses—this triggers severe mobilization flares 6
• Do not skip prophylaxis—acute attacks increase during the first 6 months of ULT even when urate levels normalize 6
• Do not forget preoperative chondrocalcinosis screening before parathyroidectomy 5
• Do not overlook calcium supplementation needs post-parathyroidectomy, as hypocalcemia can occur 5