Management of Acute Hyperuricemia
For acute hyperuricemia presenting with gouty arthritis, initiate rapid anti-inflammatory therapy with NSAIDs, colchicine, or corticosteroids as first-line treatment, while deferring urate-lowering therapy until the acute flare has completely resolved. 1
Acute Anti-Inflammatory Treatment
First-Line Options
NSAIDs are the preferred initial therapy when no contraindications exist (renal impairment, peptic ulcer disease, cardiovascular disease), offering convenient dosing and good patient acceptance 1
Colchicine should be dosed at 0.5 mg three times daily (low-dose regimen), which provides equivalent efficacy to high-dose regimens while causing significantly fewer gastrointestinal side effects 2
Corticosteroids (oral, intramuscular, or intra-articular) serve as highly effective alternatives when NSAIDs and colchicine are contraindicated 1, 2
Intra-Articular Approach
- Joint aspiration followed by intra-articular corticosteroid injection is particularly effective for monoarticular presentations and when systemic therapy poses risks 2
Critical Management Principle: Do Not Start Urate-Lowering Therapy During Acute Flares
Initiating or adjusting urate-lowering therapy during an acute attack can paradoxically worsen and prolong the flare due to rapid fluctuations in serum urate causing crystal remodeling 1
If the patient is already on urate-lowering therapy, continue it at the current dose; do not stop or adjust during the acute episode 1
When to Initiate Long-Term Urate-Lowering Therapy
Indications (After Acute Flare Resolves)
- ≥2 acute gout attacks per year 2, 3
- Presence of subcutaneous tophi 1, 2
- Radiographic evidence of gouty erosions or chronic gouty arthropathy 1
- Uric acid nephrolithiasis or interstitial renal disease 3, 4
Target Serum Uric Acid Levels
- Standard target: <6 mg/dL (360 μmol/L) for all gout patients to promote crystal dissolution 2, 5
- Intensive target: <5 mg/dL for patients with severe disease including tophi, chronic arthropathy, or frequent attacks 6, 2
Urate-Lowering Therapy Protocol
Allopurinol Dosing Strategy
Start at 100 mg once daily (or 50 mg daily if stage 4 or worse chronic kidney disease) 6
Titrate upward by 100 mg increments every 2-4 weeks based on serum uric acid monitoring until target is achieved 6
Most patients require >300 mg daily to reach target; more than 50% fail with 300 mg or less 6
Maximum dose: 800 mg daily, with doses >300 mg given as divided doses 6
Flare Prophylaxis During Urate-Lowering Therapy Initiation
Mandatory colchicine 0.5-1 mg daily (or low-dose NSAID if colchicine contraindicated) should be started concurrently with urate-lowering therapy 6, 2
Continue prophylaxis for at least 3-6 months after initiating or adjusting urate-lowering therapy, as rapid urate reduction triggers acute flares 6
Monitoring Schedule
- Check serum uric acid every 2-4 weeks during dose titration 6, 2
- Once target achieved, monitor every 6 months 6
- Monitor renal and liver function with dose adjustments, especially in chronic kidney disease 7
Common Pitfalls to Avoid
Do not treat asymptomatic hyperuricemia alone without documented gout flares, tophi, or radiographic damage 7
Do not rely on the outdated "standard 300 mg allopurinol dose" as this fails to achieve target urate levels in the majority of patients 6
Do not discontinue allopurinol after symptom control, as approximately 87% of patients experience recurrence within 5 years of discontinuation 6
Do not use outdated renal dosing algorithms that cap allopurinol at 300 mg in renal impairment; doses can be safely increased with proper monitoring 6
Non-Pharmacologic Management
- Weight loss if obese 1, 2
- Reduce alcohol consumption, particularly beer 1, 4
- Avoid sugar-sweetened beverages and foods high in fructose 2
- Encourage low-fat dairy products, coffee, and cherries 2
- Review and modify medications that elevate uric acid (thiazide diuretics, loop diuretics, low-dose aspirin) 1