From the Guidelines
Asymptomatic hyperuricemia does not require treatment, and the current recommendation is to monitor asymptomatic patients with elevated uric acid levels rather than initiating urate-lowering therapy. This approach is based on the most recent and highest quality study, which conditionally recommends against initiating urate-lowering therapy (ULT) in patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi) 1. The rationale for this approach is that many people with elevated uric acid levels never develop gout or complications, and the potential risks of long-term medication use may outweigh the benefits in asymptomatic individuals.
Key Considerations
- The 2020 American College of Rheumatology guideline for the management of gout recommends against initiating ULT in patients with asymptomatic hyperuricemia, except in certain situations such as frequent gout flares, radiographic damage, or subcutaneous tophi 1.
- Lifestyle modifications, including weight loss, limiting alcohol intake, reducing consumption of purine-rich foods, and staying well-hydrated, are recommended for all patients with hyperuricemia.
- If treatment becomes necessary due to the development of symptoms, medications such as allopurinol or febuxostat may be prescribed, with the goal of achieving a target serum urate level below 6 mg/dL 1.
Treatment Approach
- Treatment is typically reserved for patients who develop gout attacks, kidney stones, or other complications related to hyperuricemia.
- Medications such as allopurinol (starting at 100mg daily and titrating up as needed) or febuxostat (40-80mg daily) may be prescribed if treatment becomes necessary.
- The treatment target is serum urate below 6 mg/dL, and monitoring should include serum urate level, frequency of gout attacks, and tophi size 1.
From the FDA Drug Label
Asymptomatic hyperuricemia is not an indication for treatment with allopurinol tablets (see INDICATIONS AND USAGE) THIS IS NOT AN INNOCUOUS DRUG. IT IS NOT RECOMMENDED FOR THE TREATMENT OF ASYMPTOMATIC HYPERURICEMIA.
No, asymptomatic hyperuricemia should not be treated with allopurinol, as stated in the drug label 2 and 2.
From the Research
Treatment of Asymptomatic Hyperuricemia
- The treatment of asymptomatic hyperuricemia is not recommended nor excluded by current guidelines 3.
- There is no consensus on starting urate-lowering therapy (ULT) in cases of asymptomatic hyperuricemia, and the decision to treat should be made on a case-by-case basis 4.
- Treatment of asymptomatic hyperuricemia is not necessary in most patients, unless they have very high levels of uric acid or are otherwise at risk of complications 5.
Considerations for Treatment
- The presence of urate crystals in the urine sediment and/or signs of asymptomatic articular damage by urates, identified by musculo-skeletal ultrasound, may guide the treatment of asymptomatic hyperuricemia 3.
- A watchful analysis of the trend in creatinine/eGFR, proteinuria or urate levels may also guide the clinician in deciding whether to treat asymptomatic hyperuricemia 3.
- The potential benefits of urate-lowering therapy must be weighed against its potential for harm, including severe adverse hypersensitivity reactions 4.
Association with Comorbidities
- Asymptomatic hyperuricemia is associated with multiple comorbidities, including hypertension, chronic kidney disease, coronary artery disease, and diabetes 6.
- Treatment studies suggest that urate lowering may reduce the risk of incidence or progression of some of these comorbidities, but additional prospective trials are needed to establish causality 6.
- Elevated uric acid levels are reported to have an impact on the risk of cardiovascular events, but whether it is a causal agent and a possible therapeutic target is still uncertain 7.