What is the recommended therapy for a patient with pain in both feet and hyperuricemia (elevated uric acid level)?

Recommended Therapy for Bilateral Foot Pain with Uric Acid 7.4 mg/dL

Immediate Treatment Decision

You should initiate urate-lowering therapy with allopurinol, starting at 100 mg daily, while simultaneously treating the acute pain with NSAIDs, corticosteroids, or low-dose colchicine, and providing prophylaxis against future flares. 1

Acute Pain Management

Your patient likely has an acute gout attack affecting both feet. Treat the acute inflammation immediately with one of the following first-line options:

• NSAIDs (if no contraindications such as renal impairment, GI disease, or cardiovascular risk) 1, 2
• Corticosteroids (oral, intravenous, or intra-articular) if NSAIDs are contraindicated 2
• Low-dose colchicine (equally effective as high-dose but with significantly fewer gastrointestinal side effects) 1, 2

Do not delay treatment—the most important determinant of success is how soon therapy is initiated, not which specific agent you choose. 3

Urate-Lowering Therapy (ULT)

Why Start ULT Now

With a uric acid of 7.4 mg/dL (above the saturation point of 6.8 mg/dL) and bilateral foot pain suggesting recurrent gout, you should initiate allopurinol as first-line urate-lowering therapy. 1 The 2020 ACR guidelines strongly recommend allopurinol as the preferred first-line agent for all patients due to its efficacy, tolerability, safety, and lower cost. 1

Allopurinol Dosing Strategy

• Start at 100 mg daily (or 50 mg daily if the patient has stage 4 or worse CKD) 1
• Titrate upward every 2-5 weeks by 100 mg increments until serum uric acid is below 6 mg/dL 1, 4
• Target serum uric acid <6 mg/dL to prevent crystal formation, dissolve existing crystals, and eliminate future flares 1, 2, 5
• The dose can be increased above 300 mg daily (up to maximum 800 mg daily) even with renal impairment, provided you monitor for toxicity (rash, pruritus, elevated liver enzymes) 1, 4

Can You Start Allopurinol During an Acute Attack?

Yes—you can and should start allopurinol during the acute attack if the patient meets criteria for ULT. 6 A randomized controlled trial demonstrated that initiating allopurinol during an acute, treated gout attack does not prolong the attack (15.4 days vs 13.4 days; P=0.5). 6 The 2020 ACR guidelines support this approach. 1

Mandatory Flare Prophylaxis

All patients starting urate-lowering therapy require prophylactic anti-inflammatory medication to prevent acute flares during the initial treatment period. 2

• Use low-dose colchicine or low-dose NSAIDs as first-line prophylaxis 2
• Continue prophylaxis for at least 6 months (moderate-strength evidence shows duration should exceed 8 weeks) 1, 7
• Do not stop prophylaxis prematurely, as this is a common pitfall leading to treatment failure 1

Monitoring Strategy

• Check serum uric acid every 2-5 weeks during dose titration to ensure levels remain below 6 mg/dL 1, 2, 4
• Once stable, monitor every 6 months 7
• Assess renal function before initiating therapy and periodically thereafter, especially if increasing doses 1, 8
• Monitor for allopurinol toxicity (rash, pruritus, elevated transaminases) 1, 8

Special Considerations and Pitfalls

Renal Function Assessment

Before prescribing, assess the patient's creatinine clearance. If CrCl is 10-20 mL/min, use 200 mg daily maximum; if <10 mL/min, do not exceed 100 mg daily. 4 However, with normal or mildly impaired renal function, you can safely titrate above 300 mg daily with monitoring. 1

HLA-B*5801 Testing

Consider genetic testing before initiating allopurinol in high-risk populations (Korean patients with stage 3 or worse CKD; Han Chinese and Thai patients regardless of renal function) to reduce risk of allopurinol hypersensitivity syndrome. 1, 8

Common Pitfalls to Avoid

• Do not start with 300 mg daily—this increases toxicity risk and flare risk 1
• Do not stop existing ULT during an acute attack if the patient is already on therapy 2
• Do not use uricosuric agents (probenecid) as first-line therapy in this patient—they are inferior to xanthine oxidase inhibitors and contraindicated if CrCl <50 mL/min 1
• Do not treat asymptomatic hyperuricemia alone—but this patient has symptomatic disease 1, 4

Alternative if Allopurinol Fails or Is Not Tolerated

If the patient develops intolerance or adverse events to allopurinol, substitute febuxostat (starting at ≤40 mg daily with subsequent titration). 1 Febuxostat can be used without dose adjustment in mild to moderate renal impairment. 8