When urate-lowering treatment is indicated for gout, take it consistently and maintain serum urate below 360 µmol/L

Allopurinol costs a few to a few tens of RMB monthly in China. Initially, urate checks every few weeks guide dosage; after stabilization, checks are every few months. Preventive anti-inflammatory treatment is also needed for the first 3–6 months. Continuing when pain-free is difficult.

A randomized trial enrolled 517 adults with a flare in the preceding 12 months. Nurse-led education, engagement and treat-to-target adjustment was compared with usual GP care. At two years, serum urate <360 µmol/L (6 mg/dL) was achieved in 95% versus 30%, RR 3.18, 95% CI 2.42–4.18, P<0.0001. Second-year flares, tophi and quality-of-life secondary outcomes also favored nurse-led care. Cost per additional quality-adjusted life-year was £5,066. A follow-up questionnaire went to 438 participants, with 82% responding. Self-reported previous-year flare medians were 0 (interquartile range 0–0) in the target-led group versus 1 (0–3) in usual care, P<0.001. Continued urate-lowering use had adjusted RR 1.19 (1.09–1.30). The 2020 American College of Rheumatology guideline strongly recommends starting urate lowering for subcutaneous tophi, gout-related radiographic damage or at least 2 flares yearly. It recommends serial serum-urate measurement and titration to <6 mg/dL. Allopurinol is first-line, including in stage 3 or worse chronic kidney disease, starting at ≤100 mg/day. Add anti-inflammatory prophylaxis for at least 3–6 months. A cited observational series of patients stopping after long-term control, whose urate remained <7 mg/dL, found only 13% (27/211) flare-free over 5 years. Limiting/abstaining from alcohol was associated with serum urate 1.6 mg/dL lower than without restriction; one beer serving with a 0.16 mg/dL rise. Healthy, Mediterranean and DASH dietary patterns had smaller effects. Drug choice is disputed: ACR favors allopurinol for efficacy at adequate dose, tolerability, safety and cost, and conditionally recommends switching from febuxostat after cardiovascular disease/events where an alternative exists, consistent with the FDA boxed warning. CARES randomized 6,190 gout patients with cardiovascular disease to febuxostat or allopurinol: all-cause mortality HR 1.22 (1.01–1.47), about 22% higher, and cardiovascular mortality HR 1.34 (1.03–1.73), about 34% higher, with febuxostat. Europe's FAST trial differed: among 6,128 people over 60 with cardiovascular risk factors, febuxostat was noninferior for major cardiovascular events, HR 0.85 (0.70–1.03); deaths were 7.2% versus 8.6%. For uricosuric drugs, ACR conditionally recommends against urine alkalinization because evidence of benefit is absent and certainty very low. It advises adequate hydration and avoiding these drugs in known kidney stones or stage 3-or-worse kidney disease.

Disputed: national guidelines differ on drug choice. US guidance favors allopurinol and switching from febuxostat in cardiovascular disease where feasible, while FAST did not find excess risk. Benzbromarone, a uricosuric, is available in China. Chinese guidelines from 2019 and the 2024 update separately address drug choice and alkalinization. For adding sodium bicarbonate with benzbromarone, ACR finds inadequate evidence; follow your clinician's advice and maintain hydration. Han Chinese patients should discuss HLA-B*5801 testing before allopurinol. This inherited immune-related gene variant is lifelong; the cited prevalence is 7.4% in Han Chinese, Korean and Thai populations versus 0.7% in White and Hispanic populations. Asian and African American patients have about three times the White population's risk of allopurinol hypersensitivity syndrome, which can cause extensive skin loss and death. ACR conditionally recommends pre-treatment testing in these higher-risk groups. Starting urate lowering can initially trigger flares, hence 3–6 months of anti-inflammatory prophylaxis. Stopping because it initially hurts more is a common failure; use prescribed anti-inflammatory treatment rather than stopping urate lowering on your own. The target <6 mg/dL is approximately 360 µmol/L, the unit commonly used in China. Asymptomatic high urate is a separate issue; see Chapter 6, entry 19, sugary drinks and alcohol.

Doherty M, Jenkins W, Richardson H, et al. (2018). Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet, 392(10156), 1403-1412. https://doi.org/10.1016/S0140-6736(18)32158-5; Abhishek A, Jenkins W, La-Crette J, Fernandes G, Doherty M (2020). Nurse-led care is preferred over GP-led care of gout and improves gout outcomes: results of Nottingham Gout Treatment Trial follow-up study. Rheumatology, 59(3), 575-579. https://doi.org/10.1093/rheumatology/kez333; FitzGerald JD, Dalbeth N, Mikuls T, et al. (2020). 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research, 72(6), 744-760. https://doi.org/10.1002/acr.24180; White WB, Saag KG, Becker MA, et al.; CARES Investigators (2018). Cardiovascular Safety of Febuxostat or Allopurinol in Patients with Gout. New England Journal of Medicine, 378(13), 1200-1210. https://doi.org/10.1056/NEJMoa1710895; Mackenzie IS, Ford I, Nuki G, et al.; FAST Study Group (2020). Long-term cardiovascular safety of febuxostat compared with allopurinol in patients with gout (FAST): a multicentre, prospective, randomised, open-label, non-inferiority trial. Lancet, 396(10264), 1745-1757. https://doi.org/10.1016/S0140-6736(20)32234-0; Chinese Society of Endocrinology (2020). Chinese Guideline for Diagnosis and Treatment of Hyperuricemia and Gout (2019). Chinese Journal of Endocrinology and Metabolism, 36(1), 1-13. https://doi.org/10.3760/cma.j.issn.1000-6699.2020.01.001