and with 600mg allopurinol daily, his serum urate
dropped to 320 micromolar (5.37mg/dl) with urate
excretion 1.2mM (20mg/dl) and FeUA 2.6% (a very
low urate clearance enabling hyperuricaemia) with
GFR >60. The serum urate level reached was < 360
micromolar (<6mg/dl) range recommended by ACR
EULAR demand, so can be called adequate.
With the available guidelines for gout treatment
(BSR, ACP, EULAR), we need to treat up to
a predefined target and thus escalate doses of XOIs
to achieve success. In similar complex gout cases
having specialised care, the serum urate target often
is set at 300 micromolar (5mg/dl); particularly in
young persons with an adequate renal function, an
escalation regimen with allopurinol is the rational
course of action. In some patients, the pre-defined
target of 300 micromolar is not reached and adding
a uricosuric should be considered at some stage. But
if the clinical situation reached is adequate, there
is no requirement to pursue the <300 micromolar
target (<5mg/dl) as literature lacks clear evidence for
doing so.
Case study 3
cartilage, tophaceous debris (in subcutaneous tissue)
and gout attacks. These attacks may vary from mild
arthropathy to severe debilitating attacks and can be
sporadic, recurrent or continous. Even in the milder
cases, treating to a significantly lower serum urate
target resolves locomotor problems fully. Common
doses of XOIs can help with this eradication
perfectly. Many general practitioners therefore
prescribe up to 300mg allopurinol (to reach the
treatment goal of serum uric acid <0.36mmol/l
(<6mg/dl)) . Up-titration of the allopurinol dose
in such cases is often not needed; what is needed,
however, is a second measurement of serum urate in
order to know whether the predefined serum urate
target has been reached.
Case study 2
An overweight 50-year-old man with hypertension
and a family history of gout (father had gout) who
suffered from an annual gout attack in the big toe
over a three-year period, now presenting with
a debilitating gonarthritis. He was unable to walk
without assistance and could not work. He used
a betablocker and thiazide, and regularly consumed
alcohol, particularly at weekends.
Physical examination Healthy appearance, BMI
31.5 with some residual redness over his knee joint,
unilaterally
Ultrasonography Double contour sign leftsided
MTP1 and affected knee with grade 2 power Doppler
X-rays forefeet Slight degeneration MTP1 with
a subcortical cyst
Gout calculator Score 9.5 (highly suggestive
for gout)
Laboratory test Serum urate 640 micromolar
(10.76mg/dl) with GFR >60 serum creatinine 90 ESR
30 and CRP 15.0; urate excretion 4.0mM (67.2mg/dl);
fractional urate excretion 2.6% (urine portion)
Course Dietary advice with colchicine 0.5mg twice
daily. Glucocorticoid injection in the knee provided
instant relief and allowed the opportunity to look for
crystals under polarised light microscopy.
Allopurinol also initiated: with 300mg daily,
his urate dropped to 400 micromolar (6.72mg/dl),
A 59-year-old man (slightly overweight) and
a family history of gout (father had gout) and
suffering from an protracted gout attack in the big
toe during several months. He had suffered gout
for for more than ten years, having just one attack
annually. However, he was now unable to do his job,
and had difficulty walking and sleeping. He used
simvastatin for his elevated serum cholesterol and
a puffer for bronchial hyper-reactivity, had a normal
diet with regular, moderate alcohol consumption,
particularly in the weekends.
Physical examination A healthy man with weight
83kg and BMI 26.8 with some redness over his
painful MTP1 joint, unilaterally.
Ultrasonography Double contour sign leftsided
MTP1 with grade 2 power Doppler
X-rays forefeet Slight degeneration MTP1 with
a subcortical cyst and overhanging edge.
Gout calculator: score 10.5 ( highly suggestive
for gout)
Laboratory test Serum urate 620 micromolar
(10.42mg/dl) with GFR>60 serum creatinine 90 ESR
40 and CRP 20.0; fractional urate excretion 2.6%
(urine portion). This is a very low urate clearance
leading to hyperuricaemia.
Course Initially dietary advice (reduce calories
and purine ingestion/stop beer and increase coffee
intake) and stick to 100 grams of meat daily with
colchicine 0.5mg twice daily.
Started allopurinol: with 300mg daily, his urate
dropped to 370 micromolar (6.22mg/dl) with urate
excretion 0.4mM (6.72mg/dl), and with 300mg
allopurinol plus 100mg benzbromarone daily, his
serum urate dropped to 190 micromolar (3.19mg/
dl), with fractional urate excretion 12.1% with
GFR >60. After one year, ultrasonography showed
no double contour sign. Advised continuation of
300mg allopurinol monotherapy, resulting in an
asymptomatic disease
The combined use of XOI plus uricosuric can be very
useful for rapid debulking. Most patients do tolerate
the combination and will reach serum urate levels
<200 micromolar, enabling a rapid dissolution of
monosodium urate crystals. This, of course, can
be performed safely when renal function is still
adequate as uricosuria is a challenge for the tubules
and renal function in general. Not all patients
require lifelong XOIs plus uricosurics, but it can
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