So how should we manage hyperuricemia in patients with gout?
When patients have indications for starting urate lowering therapy such as the presence of complications (tophi, arthropathy and uric acid nephrolithiases), >2 flares of gouty arthritis, and in cases of difficult to manage gout (patients with concomitant heart failure and kidney disease), Allopurinol should be the initial drug to be started. If the patient develops allopurinol hypersensitivity syndrome, SJS or is intolerant to side effects of Allopurinol, the patient may then be shifted to a uricosuric agent (sulfinpyrazone is available in the Philippines through Watson’s pharmacies; starting dose is 100 mg BID to a maximum of 800 mg/day).
If hyperuricemia remains uncontrolled on maximum acceptable doses of uricosuric agent or allopurinol, the patient should then be shifted to Febuxostat. There are still no guidelines on how to give Febuxostat but the 40 mg dose is equivalent in efficacy to 300 mg Allopurinol. The dose of Febuxostat may be increased every 2 weeks by 40 mg up to a maximum of 240 mg/day. If the patient still has uncontrolled hyperuricemia on Febuxostat, tophi debulking with uricase may be considered for select patients.
Another option worth considering in patients uncontrolled on monotherapy ULT is to combine Allopurinol with a uricosuric agent. However, there are no RCTs to show the efficacy of the combination but there have been small trials showing urate lowering ability using lower doses of allopurinol and uricosuric agents.
How will controlling hyperuricemia be different in gout patients with chronic kidney disease?
Basically, therapy would be limited to Allopurinol, Febuxostat and Pegloticase as shown above. If the novel drug RDEA594 becomes available, combination with Allopurinol and Febuxostat may be worth considering also.
Terkeltaub R. Update on gout: new therapeutic strategies and option. Nat Rev Rheumatol 2010; 6: 30-38.