In an asymptomatic pregnant patient with hyperuricemia, should urate‑lowering therapy be initiated?

Treatment of Hyperuricemia in Pregnancy

Do not initiate urate-lowering therapy for hyperuricemia in pregnancy. The FDA explicitly contraindicates allopurinol for asymptomatic hyperuricemia, and no guidelines support pharmacologic treatment of elevated uric acid during pregnancy in the absence of symptomatic gout. 1

Why Hyperuricemia Occurs in Pregnancy

• Elevated uric acid is common in preeclamptic pregnancies and often appears early, even before clinical manifestations develop. 2
• Hyperuricemia in pregnancy is typically secondary to altered renal function and placental dysfunction, not a primary disease requiring treatment. 2
• While elevated uric acid associates with adverse fetal outcomes in hypertensive pregnancies, this represents a marker of disease severity rather than a treatment target. 2

Evidence Against Treatment in Asymptomatic Hyperuricemia

The American College of Rheumatology conditionally recommends against initiating urate-lowering therapy for asymptomatic hyperuricemia based on high-certainty evidence. 3, 4

• The number needed to treat is prohibitively high: 24 patients require therapy for 3 years to prevent a single gout flare. 3, 4
• Only 20% of individuals with asymptomatic hyperuricemia—even those with serum urate >9 mg/dL—develop gout within 5 years. 3, 4
• The FDA drug label for allopurinol explicitly states: "THIS IS NOT AN INNOCUOUS DRUG. IT IS NOT RECOMMENDED FOR THE TREATMENT OF ASYMPTOMATIC HYPERURICEMIA." 1

Pregnancy-Specific Considerations

• No evidence supports that treating asymptomatic hyperuricemia in pregnancy prevents preeclampsia, improves fetal outcomes, or reduces maternal complications. 2
• Urate-lowering medications carry potential risks including hypersensitivity reactions (sometimes fatal with allopurinol) that outweigh any theoretical benefit in asymptomatic pregnant patients. 5, 6
• Hyperuricemia in pregnancy should prompt evaluation for preeclampsia and appropriate obstetric management, not pharmacologic urate lowering. 2

When Urate-Lowering Therapy IS Indicated (Not Applicable to Typical Pregnancy)

Treatment is only appropriate for symptomatic gout with specific high-risk features: 3, 4

• Presence of subcutaneous tophi on physical exam or imaging
• Radiographic joint damage attributable to gout
• Frequent gout flares (≥2 per year)
• Chronic kidney disease stage ≥3 (eGFR <60 mL/min) after a first gout flare
• Serum urate >9 mg/dL after a documented gout flare

Management Strategy for Pregnant Patients with Hyperuricemia

Focus on the underlying condition, not the uric acid level: 2

• Monitor for signs and symptoms of preeclampsia (hypertension, proteinuria, end-organ dysfunction)
• Assess renal function and fetal well-being through appropriate obstetric surveillance
• Coordinate care with obstetrics for management of hypertensive disorders of pregnancy
• Avoid urate-lowering medications unless the patient has established, symptomatic gout requiring treatment

Common Pitfalls to Avoid

• Treating the number: Elevated uric acid in pregnancy is a laboratory marker, not a disease requiring pharmacologic intervention. 3, 1
• Misinterpreting associations as causation: While hyperuricemia associates with preeclampsia and adverse outcomes, no evidence shows that lowering uric acid improves these outcomes. 2, 5
• Exposing patients to unnecessary medication risks: Allopurinol can cause severe hypersensitivity reactions, and the risk-benefit ratio is unfavorable in asymptomatic patients. 5, 6
• Ignoring the underlying pathology: Hyperuricemia in pregnancy reflects placental dysfunction and altered renal handling; address the preeclampsia, not the uric acid. 2