Table 2.

Suggested, current experience-based strategy for initiation of antihyperuricemic therapy6

Confirmation of diagnosis: detect urate crystals by means of polarization microscopy Two or more gout flares per year or tophi/joint destruction due to gout attacks Therapeutic advicea: allopurinol 100–300 mg/db allopurinol intolerance: consider febuxostat Laboratory monitoring of the effectiveness at 6–8 wkc: sUr < 0.30 mmol/L, then continue allopurinol sUr > 0.30–0.36 mmol/L, but no further attacks (without colchicine/NSAID/corticosteroids), then continue allopurinol sUr > 0.30 mmol/L plus gout attacks/persistent tophi and uUr > 1.5 mmol/24 h, go to 5 sUr > 0.30 mmol/L plus gout attacks/persistent tophi with uUr < 1.5 mmol/24 h, go to 6 Therapeutic advice: increase allopurinol (eg, +100 mg/d or double the dose); then go to 4 Allopurinol inefficacy at maximum dosage (corrected for renal function): consider febuxostat Therapeutic advice: add uricosuricum, eg, benzbromarone 100 mg/d or probenecid 500 mg twice daily; then go to 4 Laboratory monitoring of the effectiveness of sUr and uUr (possibly pHd) after 6 mo: see 5 Note: when trying to clear tophi, target value is sUr < 0.30 mmol/L. Consider pegloticase when target value cannot be reached with conventional oral drugs or for more rapid debulkment in severe bulky disease

^aNotes: Subject to motivation and tolerance by patient;

^bSubject to calculated creatinine clearance (cCC) > 50 mL/min, if cCC < 50 mL/min, then only increase allopurinol with 100 mg/day. Serum oxipurinol concentrations might be measured in patients with renal insufficiency;

^cTarget value for sUr ≤ 0.36 mmol/L might be sufficient when there are no further gout attacks despite withdrawing colchicine/NSAID, otherwise lower target value of 0.30 mmol/L;

^dIf experiencing kidney stones or uUr > 6.0 mmol/24 hours and pH < 7.0 consider alkalizing with sodium bicarbonate.

Abbreviations: sUr, serum urate; NSAID, nonsteroidal anti-inflammatory drug; uUr, 24-hour excretion of urate in urine.