Guidelines Summary

In 2020, the American College of Rheumatology released updated guidelines on the management of gout. The guidelines strongly recommend initiation of urate-lowering therapy (ULT) for patients the following indications^[44]:

1 or more subcutaneous tophi
Evidince of radiographic damage attributable to gout
Frequent gout flares (>2/year)

ULT is conditional recommended for patients with following indications^[44]:

History of >1 flare and infrequent flares (< 2/year)
First flare and CKD stage >3, SU >9 mg/dl, or urolithiasis

The guidelines included the following additional strong recommendations^[44]:

Allopurinol is the preferred first-line urate-lowering therapy (ULT) for all patients
An xanthine oxidase inhibitor is recommended over probenecid for patients with CKD stage >3.
Allopurinol and febuxostat should be initiated at a low dose with subsequent titration to target
Concomitant antiinflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) for 3–6 months with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.
The choice of specific antiinflammatory prophylaxis should be based upon patient factors.
Oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) are appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH
The choice of colchicine, NSAIDs, or glucocorticoids should be made based on patient factors and preferences
When colchicine is the chosen agent, low-dose colchicine is preferred over high-dose colchicine given its similar efficacy and fewer adverse effects.

Medication

George C, Minter DA. Hyperuricemia. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Stack A, Manolis AJ, Ritz E. Detrimental role of hyperuricemia on the cardio-reno-vascular system. Curr Med Res Opin. 2015 Sep. 31 Suppl 2:21-6. [QxMD MEDLINE Link].
Johnson RJ, Kivlighn SD, Kim YG, Suga S, Fogo AB. Reappraisal of the pathogenesis and consequences of hyperuricemia in hypertension, cardiovascular disease, and renal disease. Am J Kidney Dis. 1999 Feb. 33(2):225-34. [QxMD MEDLINE Link].
Yin H, Liu N, Chen J. The Role of the Intestine in the Development of Hyperuricemia. Front Immunol. 2022. 13:845684. [QxMD MEDLINE Link]. [Full Text].
Enomoto A, Kimura H, Chairoungdua A, Shigeta Y, Jutabha P, Cha SH, et al. Molecular identification of a renal urate anion exchanger that regulates blood urate levels. Nature. 2002 May 23. 417(6887):447-52. [QxMD MEDLINE Link].
Ichida K, Hosoyamada M, Kimura H, Takeda M, Utsunomiya Y, Hosoya T, et al. Urate transport via human PAH transporter hOAT1 and its gene structure. Kidney Int. 2003 Jan. 63(1):143-55. [QxMD MEDLINE Link].
Leal-Pinto E, Cohen BE, Lipkowitz MS, Abramson RG. Functional analysis and molecular model of the human urate transporter/channel, hUAT. Am J Physiol Renal Physiol. 2002 Jul. 283 (1):F150-63. [QxMD MEDLINE Link].
Shiraishi H, Une H. The effect of the interaction between obesity and drinking on hyperuricemia in Japanese male office workers. J Epidemiol. 2009. 19(1):12-6. [QxMD MEDLINE Link]. [Full Text].
Martinon F, Petrilli V, Mayor A, Tardivel A, Tschopp J. Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature. 2006 Mar 9. 440(7081):237-41. [QxMD MEDLINE Link].
Dalbeth N, Merriman T. Crystal ball gazing: new therapeutic targets for hyperuricaemia and gout. Rheumatology (Oxford). 2009 Mar. 48(3):222-6. [QxMD MEDLINE Link].
Latourte A, Bardin T, Richette P. Prophylaxis for acute gout flares after initiation of urate-lowering therapy. Rheumatology (Oxford). 2014 Nov. 53 (11):1920-6. [QxMD MEDLINE Link].
Xie DX, Xiong YL, Zeng C, Wei J, Yang T, Li H, et al. Association between low dietary zinc and hyperuricaemia in middle-aged and older males in China: a cross-sectional study. BMJ Open. 2015 Oct 13. 5 (10):e008637. [QxMD MEDLINE Link].
Wang YL, Zeng C, Wei J, Yang T, Li H, Deng ZH, et al. Association between Dietary Magnesium Intake and Hyperuricemia. PLoS One. 2015. 10 (11):e0141079. [QxMD MEDLINE Link].
Zhang Y, Qiu H. Dietary Magnesium Intake and Hyperuricemia among US Adults. Nutrients. 2018 Mar 2. 10 (3):[QxMD MEDLINE Link]. [Full Text].
Zhang Y, Liu Y, Qiu H. Association between Dietary Zinc Intake and Hyperuricemia among Adults in the United States. Nutrients. 2018 May 5. 10 (5):[QxMD MEDLINE Link]. [Full Text].
Chen SC, Huang YF, Wang JD. Hyperferritinemia and hyperuricemia may be associated with liver function abnormality in obese adolescents. PLoS One. 2012. 7(10):e48645. [QxMD MEDLINE Link]. [Full Text].
Lee YM, Bae SG, Lee SH, Jacobs DR Jr, Lee DH. Persistent organic pollutants and hyperuricemia in the U.S. general population. Atherosclerosis. 2013 Sep. 230(1):1-5. [QxMD MEDLINE Link].
Rho YH, Zhu Y, Choi HK. The epidemiology of uric acid and fructose. Semin Nephrol. 2011 Sep. 31(5):410-9. [QxMD MEDLINE Link]. [Full Text].
Bae J, Chun BY, Park PS, Choi BY, Kim MK, Shin MH, et al. Higher consumption of sugar-sweetened soft drinks increases the risk of hyperuricemia in Korean population: The Korean Multi-Rural Communities Cohort Study. Semin Arthritis Rheum. 2014 Apr. 43(5):654-61. [QxMD MEDLINE Link].
López-Molina R, Parra-Cabrera S, López-Ridaura R, González-Villalpando ME, Ferrannini E, González-Villalpando C. Sweetened beverages intake, hyperuricemia and metabolic syndrome: the Mexico City Diabetes Study. Salud Publica Mex. 2013 Dec. 55(6):557-63. [QxMD MEDLINE Link].
Siqueira JH, Mill JG, Velasquez-Melendez G, Moreira AD, Barreto SM, Benseñor IM, et al. Sugar-Sweetened Soft Drinks and Fructose Consumption Are Associated with Hyperuricemia: Cross-Sectional Analysis from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Nutrients. 2018 Jul 27. 10 (8):[QxMD MEDLINE Link]. [Full Text].
Lecoultre V, Egli L, Theytaz F, Despland C, Schneiter P, Tappy L. Fructose-induced hyperuricemia is associated with a decreased renal uric acid excretion in humans. Diabetes Care. 2013 Sep. 36(9):e149-50. [QxMD MEDLINE Link]. [Full Text].
Chen-Xu M, Yokose C, Rai SK, Pillinger MH, Choi HK. Contemporary Prevalence of Gout and Hyperuricemia in the United States and Decadal Trends: The National Health and Nutrition Examination Survey, 2007-2016. Arthritis Rheumatol. 2019 Jun. 71 (6):991-999. [QxMD MEDLINE Link]. [Full Text].
Desideri G, Puig JG, Richette P. The management of hyperuricemia with urate deposition. Curr Med Res Opin. 2015 Sep. 31 Suppl 2:27-32. [QxMD MEDLINE Link].
Meneses-Leon J, Denova-Gutiérrez E, Castañón-Robles S, Granados-García V, Talavera JO, Rivera-Paredez B, et al. Sweetened beverage consumption and the risk of hyperuricemia in Mexican adults: a cross-sectional study. BMC Public Health. 2014 May 12. 14:445. [QxMD MEDLINE Link].
Liu L, Lou S, Xu K, Meng Z, Zhang Q, Song K. Relationship between lifestyle choices and hyperuricemia in Chinese men and women. Clin Rheumatol. 2012 Nov 7. [QxMD MEDLINE Link].
Ioannou GN, Boyko EJ. Effects of menopause and hormone replacement therapy on the associations of hyperuricemia with mortality. Atherosclerosis. 2012 Oct 22. [QxMD MEDLINE Link].
Kubota M. Hyperuricemia in Children and Adolescents: Present Knowledge and Future Directions. J Nutr Metab. 2019. 2019:3480718. [QxMD MEDLINE Link]. [Full Text].
Kim SY, De Vera MA, Choi HK. Gout and mortality. Clin Exp Rheumatol. 2008 Sep-Oct. 26(5 Suppl 51):S115-9. [QxMD MEDLINE Link].
Lin F, Zhang H, Huang F, Chen H, Lin C, Zhu P. Influence of changes in serum uric acid levels on renal function in elderly patients with hypertension: a retrospective cohort study with 3.5-year follow-up. BMC Geriatr. 2016 Feb 3. 16 (1):35. [QxMD MEDLINE Link].
Ding X, Zeng C, Wei J, Li H, Yang T, Zhang Y, et al. The associations of serum uric acid level and hyperuricemia with knee osteoarthritis. Rheumatol Int. 2016 Jan 7. [QxMD MEDLINE Link].
Yang T, Ding X, Wang YL, Zeng C, Wei J, Li H, et al. Association between high-sensitivity C-reactive protein and hyperuricemia. Rheumatol Int. 2016 Feb 10. [QxMD MEDLINE Link].
Li M, Hou W, Zhang X, Hu L, Tang Z. Hyperuricemia and risk of stroke: a systematic review and meta-analysis of prospective studies. Atherosclerosis. 2014 Feb. 232 (2):265-70. [QxMD MEDLINE Link].
Li L, Yang C, Zhao Y, Zeng X, Liu F, Fu P. Is hyperuricemia an independent risk factor for new-onset chronic kidney disease?: A systematic review and meta-analysis based on observational cohort studies. BMC Nephrol. 2014 Jul 27. 15:122. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Eckel RH, Jakicic JM, Ard JD, de Jesus JM, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 24. 129 (25 Suppl 2):S76-99. [QxMD MEDLINE Link].
Wang J, Chen Y, Zhong H, Chen F, Regenstein J, Hu X, et al. The gut microbiota as a target to control hyperuricemia pathogenesis: Potential mechanisms and therapeutic strategies. Crit Rev Food Sci Nutr. 2022. 62 (14):3979-3989. [QxMD MEDLINE Link].
Zhao H, Lu Z, Lu Y. The potential of probiotics in the amelioration of hyperuricemia. Food Funct. 2022 Mar 7. 13 (5):2394-2414. [QxMD MEDLINE Link].
Becker MA, Schumacher HR, Espinoza LR, Wells AF, MacDonald P, Lloyd E, et al. The urate-lowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: the CONFIRMS trial. Arthritis Res Ther. 2010. 12 (2):R63. [QxMD MEDLINE Link]. [Full Text].
Frampton JE. Febuxostat: a review of its use in the treatment of hyperuricaemia in patients with gout. Drugs. 2015 Mar. 75 (4):427-38. [QxMD MEDLINE Link].
Zurampic (lesinurad) [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals. December, 2015. Available at [Full Text].
Dinnel J, Moore BL, Skiver BM, Bose P. Rasburicase in the management of tumor lysis: an evidence-based review of its place in therapy. Core Evid. 2015. 10:23-38. [QxMD MEDLINE Link]. [Full Text].
Mena-Sánchez G, et al; PREDIMED-PLUS investigators. Association between dairy product consumption and hyperuricemia in an elderly population with metabolic syndrome. Nutr Metab Cardiovasc Dis. 2020 Feb 10. 30 (2):214-222. [QxMD MEDLINE Link].
Zhang Y, Qiu H. Folate, Vitamin B6 and Vitamin B12 Intake in Relation to Hyperuricemia. J Clin Med. 2018 Aug 11. 7 (8):[QxMD MEDLINE Link]. [Full Text].
[Guideline] FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res (Hoboken). 2020 Jun. 72 (6):744-760. [QxMD MEDLINE Link]. [Full Text].

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Author

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Central Society for Clinical and Translational Research

Disclosure: Received research grant from: GSK<br/>Partner received salary from Alexion for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

James H Sondheimer, MD, FACP, FASN Professor of Medicine, Nephrology and Hypertension, Department of Medicine, Wayne State University School of Medicine; Medical Director, DaVita Kresge Dialysis (Detroit)

James H Sondheimer, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology

Disclosure: Nothing to disclose.

Yasir Qazi, MD Assistant Professor of Medicine, Division of Nephrology, University of Southern California at Keck School of Medicine

Yasir Qazi, MD is a member of the following medical societies: American Society of Nephrology

Disclosure: Nothing to disclose.

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