What is the appropriate management for a 54-year-old male patient with intermittent foot pain, a history of gout, and elevated uric acid levels, currently not experiencing a gout flare-up, with a previous medication regimen of allopurinol (Zyloprim) that was discontinued?

From the Guidelines

I strongly recommend starting this 54-year-old male patient with foot pain and elevated uric acid on allopurinol 100 mg once daily in the morning to target a uric acid level below 6.0 mg/dL, as supported by the 2020 American College of Rheumatology guideline for the management of gout 1. For pain management, acetaminophen 325 mg and meloxicam 7.5 mg should be used as needed. Allopurinol works by inhibiting xanthine oxidase, the enzyme responsible for uric acid production, which helps prevent gout flares over time. The low starting dose of 100 mg reduces the risk of allopurinol hypersensitivity syndrome and should be titrated upward if needed based on follow-up uric acid levels.

Some key points to consider in the management of this patient include:

• The importance of lifestyle modifications, including reducing intake of high-purine foods (red meat, seafood, beer), limiting alcohol consumption, maintaining adequate hydration, and achieving a healthy weight if overweight, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
• The need for regular follow-up appointments to monitor uric acid levels, assess medication tolerance, and adjust the treatment plan if necessary.
• The potential for gout flares to paradoxically increase when starting uric acid-lowering therapy, but this typically resolves with continued treatment.
• The use of concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3-6 months when initiating ULT, as strongly recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Overall, the goal of treatment should be to reduce the patient's uric acid level to below 6.0 mg/dL, prevent future gout flares, and improve the patient's quality of life. The treatment plan should be tailored to the individual patient's needs and should take into account any potential contraindications or interactions with other medications, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1 and the 2020 American College of Rheumatology guideline 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 patient's current uric acid level is 7.1, and the goal is to lower it to under 6.0.

• The initial dose of allopurinol 100 mg QAM is within the recommended range.
• It is recommended to increase the dose at weekly intervals by 100 mg until the target serum uric acid level is attained.
• The patient should be monitored closely, and the dose should not exceed the maximal recommended dosage of 800 mg daily 2.

From the Research

Treatment of Hyperuricemia

• The patient's current uric acid level is 7.1, and the goal is to lower it to under 6.0 with allopurinol 100 mg QAM 3, 4, 5.
• Allopurinol is a commonly used medication for hyperuricemia, but febuxostat has been shown to be more effective in some studies 3, 6, 4, 7.
• The patient will also be recommended to make lifestyle modifications, including dietary changes to reduce purine intake and increased hydration to help manage his uric acid levels.

Comparison of Allopurinol and Febuxostat

• Studies have compared the efficacy of allopurinol and febuxostat in lowering serum uric acid levels, with febuxostat showing greater potency in some cases 3, 6, 4, 7.
• A systematic review found that febuxostat may be more renoprotective than allopurinol in patients with hyperuricemia and chronic kidney disease 7.
• However, a double-blind noninferiority trial found that allopurinol was noninferior to febuxostat in controlling flares and achieving serum urate goals in patients with gout 5.

Patient Management

• The patient will be started on allopurinol 100 mg QAM and acetaminophen 325 mg, and meloxicam 7.5 mg, with a follow-up appointment in four weeks to assess his response to the treatment and adjust the regimen if necessary.
• The patient's uric acid level will be monitored, and adjustments to the treatment plan will be made as needed to achieve the target level of under 6.0.