Algorithm for Pharmacologic Serum Urate-Lowering Treatment of Hyperuricemia in Patients with a Confirmed Diagnosis of Gout

Algorithm for Pharmacologic Serum Urate-Lowering Treatment of Hyperuricemia in Patients with a Confirmed Diagnosis of Gout - Flowchart Gout Gout

«Flowchart»

PHARMACOLOGIC SERUM URATE-LOWERING TREATMENT

Symptomatic gouty arthritis and one or more of the following:

Frequent acute gout flares (≥2/yr)
CKD
Overproduction of uric acid
Urolithiasis
Palpable tophi
Severe, difficult to treat, acute gout attacks
Chronic tophaceous gouty arthritis

Symptomatic gouty arthritis and one or more of the following:

Frequent acute gout flares (≥2/yr)
CKD
Overproduction of uric acid
Urolithiasis
Palpable tophi
Severe, difficult to treat, acute gout attacks
Chronic tophaceous gouty arthritis

Symptomatic gouty arthritis and one or more of the following:

and

Frequent acute gout flares (≥2/yr)
CKD
Overproduction of uric acid
Urolithiasis
Palpable tophi
Severe, difficult to treat, acute gout attacks
Chronic tophaceous gouty arthritis

Frequent acute gout flares (≥2/yr) ≥
CKD
Overproduction of uric acid
Urolithiasis
Palpable tophi
Severe, difficult to treat, acute gout attacks
Chronic tophaceous gouty arthritis

First line: start potent oral urate-lowering monotherapy and titrate dose to appropriate maximum for the patient to treat to serum urate target; options are:

Xanthine oxidase inhibitor (XOI)^*

Allopurinol^†
Febuxostat

Potent uricosuric (alternative first line)^‡

Probenecid (where available)
Benzbromarone (where available)

First line: start potent oral urate-lowering monotherapy and titrate dose to appropriate maximum for the patient to treat to serum urate target; options are:

Xanthine oxidase inhibitor (XOI)^*

Allopurinol^†
Febuxostat

Potent uricosuric (alternative first line)^‡

Probenecid (where available)
Benzbromarone (where available)

First line: start potent oral urate-lowering monotherapy and titrate dose to appropriate maximum for the patient to treat to serum urate target; options are:

Xanthine oxidase inhibitor (XOI)^*

Allopurinol^†
Febuxostat

Potent uricosuric (alternative first line)^‡

Probenecid (where available)
Benzbromarone (where available)

Xanthine oxidase inhibitor (XOI)^* ^* ^*

Allopurinol^†
Febuxostat

Allopurinol^† ^† ^†
Febuxostat
Potent uricosuric (alternative first line)^‡ ^‡ ^‡

Probenecid (where available)
Benzbromarone (where available)

Second line: For treatment failure at appropriate maximum tolerated dose of single agent:

Combine one XOI with one uricosuric drug (e.g., probenecid, lesinurad, benzbromarone)

Second line: For treatment failure at appropriate maximum tolerated dose of single agent:

Combine one XOI with one uricosuric drug (e.g., probenecid, lesinurad, benzbromarone)

Second line: For treatment failure at appropriate maximum tolerated dose of single agent:

Combine one XOI with one uricosuric drug (e.g., probenecid, lesinurad, benzbromarone)

Third line: Reserved for severe, chronic gout and first- and second-line treatment failure:

Limited-term pegloticase therapy to resolve palpable tophi followed by return to maintenance oral urate-lowering therapy

Third line: Reserved for severe, chronic gout and first- and second-line treatment failure:

Limited-term pegloticase therapy to resolve palpable tophi followed by return to maintenance oral urate-lowering therapy

Third line: Reserved for severe, chronic gout and first- and second-line treatment failure:

and

Limited-term pegloticase therapy to resolve palpable tophi followed by return to maintenance oral urate-lowering therapy

End

^*Alternatives weighed by factors including cost of treatment, renal function and uric acid excretion, and drug tolerance.

^†Prescreen for HLA-B*5801 by PCR-based test in populations at high risk of severe allopurinol hypersensitivity reaction (e.g., Han Chinese, Thais, Koreans, blacks [African descent]).

^†

^‡Requires renal function adequate for uricusouric response. Contraindicated with uric acid overproduction or urolithiasis.

^‡