Fast Five Quiz: Gout Management

Bruce M. Rothschild, MD


August 16, 2022

The goal of long-term therapy for gout is to lower serum urate levels, reduce recurrent gout flares, resolve tophi, and prevent joint damage. According to the ACR guidelines, urate-lowering therapy is recommended for patients with gout and any of the following:

  • One or more subcutaneous tophi

  • Radiographic evidence of joint damage attributable to gout

  • Two or more gout flares annually

Urate-lowering agents are conditionally recommended in patients with moderate to severe chronic kidney disease, serum urate concentrations > 9 mg/dL, or urolithiasis to prevent renal damage. However, in patients with asymptomatic hyperuricemia with a serum urate concentration < 9 mg/dL and no prior gout flares, the initiation of pharmacotherapy is not warranted. This recommendation is based on observational studies that report a low incidence of gout in patients with asymptomatic hyperuricemia.

According to Dalbeth and colleagues, allopurinol should be started at a low dose (100 mg/d), with gradual dose escalation until target serum urate level are achieved. Rapid and intensive reductions in serum urate levels may increase the frequency of gout flares.

Allopurinol, the most commonly used urate-lowering agent, carries the risk for allopurinol hypersensitivity syndrome, particularly among positive HLA-B*5801 carriers. The ACR guidelines recommend only testing patients in selected populations at increased risk, particularly persons of Southeast Asian decent and Black persons, before the initiation of allopurinol. In addition, HLA-B*5801 testing is not required for the initiation of other urate-lowering agents.

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