Chapter 109: Gout and Hyperuricemia

KEY CONCEPTS

• In the absence of a history of gout, asymptomatic hyperuricemia is not usually treated.

• Acute gouty arthritis may be treated effectively with short courses of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine.

• Initiation of a xanthine oxidase inhibitor may be considered in patients with gout and one of the following indications for urate-lowering therapy (ULT): (a) two or more gout attacks per year, (b) the presence of one or more tophus, (c) a history of urolithiasis, (d) high-risk comorbidities including chronic kidney disease, hypertension, ischemic heart disease, or heart failure, (e) first diagnosis of gout at age <40 years, or (f) serum uric acid concentrations >8.0 mg/dL.

• According to the treat-to-target approach supported by the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) Guidelines, the goal serum urate concentration is less than 6 mg/dL [less than 357 μmol/L], or less than 5 mg/dL [less than 297 μmol/L] if signs of gout persist at a concentration of 6 mg/dL.

• Xanthine oxidase inhibitors are preferred agents for the prophylaxis of recurrent gout attacks because they are effective in both underexcreters and overproducers of uric acid.

• Uricosuric drugs are contraindicated for patients with impaired kidney function (a creatinine clearance less than 45-50 mL/min).

• Due to increased risk of acute kidney injury when used as monotherapy, lesinurad is only approved to be taken in combination with a xanthine oxidase inhibitor.

• Low-dose colchicine, NSAID, or corticosteroid therapy should be administered during the first 6 months of urate-lowering therapy (ULT) to minimize the risk of acute gout attacks that may occur during this initiation period.

• Uric acid nephrolithiasis should be treated with adequate hydration (2-3 L/day), a daytime urine-alkalinizing agent, and 60 to 80 mEq/day (mmol/day) of potassium bicarbonate or potassium citrate.

• Patients with hyperuricemia or a history of gouty arthritis should undergo comprehensive evaluation for signs and symptoms of cardiovascular disease, and aggressive management of cardiovascular risk factors (eg, weight loss, reduction of alcohol intake, control of blood pressure, glucose, and lipids) should be attempted.

Patient Care Process for Gout

Collect

• Patient characteristics (eg, age, sex, ethnicity)

• Patient medical history (see Table 109-1)

• Dietary habits that may lead to increased uric acid concentrations, including alcohol consumption, intake of high-purine foods and products containing high-fructose corn syrup

• Current medications that may contribute to hyperuricemia (see Table 109-2)

• Subjective report of acute gout symptoms

• Objective data

  • Blood pressure (BP), height, weight

  • Labs including uric acid, serum creatinine (SCr)

  • Synovial fluid aspirate

Assess

• Presence of acute gout (see Tables 109-3 and 109-5)

• Presence of hyperuricemia (>7.0 mg/dL)

• Indication for urate-lowering therapy (see Table 109-6)

• Optimal therapy given patient-specific factors (see Table 109-9)

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