uric acid level in chronic gout

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  • there is a relatively small but consistent evidence base to strongly support an association between serum uric acid level and clinical outcomes in gout
    • serum uric acid level appears to be an effective surrogate marker for treatment efficacy and long-term outcomes

    • a target serum uric acid level of <= 5mg/dl (300 µmoles/litre) is now recommended for the urate level in chronic gout (1,2)

    • key messages for primary care include (1,2):
      • the importance of initiating urate-lowering therapy - usually with allopurinol - starting at 100 mg/day and increasing the dose slowly until the target urate level (0.3 mmol/l) is reached, and monitoring thereafter regularly
      • the importance of intensive patient education with respect to the aims of treating gout and also optimising diet and lifestyle
      • treating episodes of acute gout promptly and effectively
      • tackling co-morbidities to improve cardiovascular risk
      • reducing the unnecessary use of urate-raising drugs such as thiazides and loop diuretics

Notes (2):

  • aim of long-term management is to lower serum urate levels below the physiological saturation threshold of urate in body tissues and hence both prevent formation of new MSU crystals and bring about dissolution of existing crystals
    • European League Against Rheumatism (EULAR) management recommendations advocate lowering serum urate below 360 µmol/l (6 mg/dl), which has been shown to prevent acute attacks, reduce crystal load and shrink tophi.
      • however, the British Society for Rheumatology (BSR)/British Health Professionals in Rheumatology (BHPR) guidelines recommend a more stringent target of below 300 µmol/l (5 mg/dl), based on the observation that the rate at which tophi reduce in size is directly related to the level to which serum urate is lowered
      • this was the level also suggested by the American Colleg of Rheumatology (2)
      • a sensible compromise may be that a serum urate level of below 360µmol/l should be the most conservative target for all patients but that lower levels are desirable whenever possible (4)

  • when using prophylactic treatment for gout
    • serum urate levels should be checked to guide dose escalation approximately 4 weeks after each dose increase

Reference:

Last reviewed 06/2018

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