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Source: Ernst ME, Clark EC. Gout and Hyperuricemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7997829. Accessed June 30, 2012.

  • Elevated serum uric acid concentration (>7 mg/dL [416 μmol/L] in men or >6 mg/dL [357 μmol/L] in women).

  • Idiopathic
  • Increased activity of phosphoribosyl pyrophosphate (PRPP) synthetase
  • Deficiency of hypoxanthine–guanine phosphoribosyl transferase (HGPRT)
  • Myeloproliferative and lymphoproliferative disorders
  • Cytotoxic drug therapy
  • Medications:
    • Diuretics
    • Nicotinic acid
    • Salicylates (<2 g/day)
    • Ethanol
    • Pyrazinamide
    • Levodopa
    • Ethambutol
    • Cyclosporine

  • Abnormalities in enzyme systems that regulate purine metabolism may result in overproduction of uric acid.
    • Increased activity of PRPP synthetase
    • Deficiency of HGPRT
  • Uric acid overproduction may occur because of increased breakdown of tissue nucleic acids in myeloproliferative and lymphoproliferative disorders.
  • Cytotoxic drug therapy also leads to overproduction of uric acid.
  • Drugs can decrease renal clearance of uric acid.

  • Prevalence of asymptomatic hyperuricemia in United States estimated to be 2–13%.
  • Hyperuricemia and gouty arthritis are more common in men than in women.
  • Risk of developing hyperuricemia increases with age.

Signs and Symptoms

Means of Confirmation and Diagnosis

  • Obtain medical history to determine whether patient has symptoms and to identify causes and comorbid conditions.

Laboratory Tests

  • Elevated serum uric acid level (>7 mg/dL [416 μmol/L] in men or >6 mg/dL [357 μmol/L] in women.
  • Obtain:
    • Complete blood count (CBC)
    • Serum electrolytes
    • Blood urea nitrogen
    • Creatinine
    • Glucose
    • Liver function tests
    • Fasting lipid profile
    • Calcium and phosphorus
    • Thyroid-stimulating hormone
  • Consider 24-hour urine collection for creatinine and uric acid to determine whether patient is overproducing or underexcreting uric acid.

Differential Diagnosis

  • Prevent attacks of acute gouty arthritis.
  • In some cases, normalize serum uric acid concentration.
  • Goal of urate-lowering therapy: achieve and maintain serum uric acid concentration <6 mg/dL (357 μmol/L) and preferably <5 mg/dL (297 μmol/L).

  • Consider uric-acid lowering therapy in patients with history of recurrent acute gouty arthritis and significantly elevated serum uric acid concentration.
  • Urate-lowering therapy should not begin until 6–8 weeks after resolution of acute gout episode.
  • Reduction of serum urate concentration can be accomplished by decreasing uric acid synthesis (xanthine oxidase inhibitors) or by increasing renal excretion of uric acid (uricosurics).
  • Give colchicine 0.6 mg once daily for at least first 8 weeks of antihyperuricemic therapy to minimize risk of acute attacks.

  • Reduce dietary intake of saturated fats and meats high in purines (e.g., organ meats).
  • Avoid alcohol.
  • Increase fluid intake.
  • Lose weight if obese.

  • Xanthine oxidase inhibitors
    • Allopurinol 100 mg daily initially, increased by 100 mg daily at 1-week intervals.
      • Typical doses: 100–300 mg daily, but some patients may require 600–800 mg daily.
      • Reduce dose in renal insufficiency ...

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