Long-term use of uric acid-lowering drugs after a gout diagnosis to keep blood uric acid below 360 µmol/L

Allopurinol costs only a few to several dozen yuan per month. In the beginning, blood uric acid levels must be checked every few weeks to adjust the dosage; once stable, checks can be done every few months. For the first 3 to 6 months, a separate medication to prevent gout attacks must also be taken. The real challenge is remembering to take these drugs consistently even when there are no symptoms.

This is a randomized controlled trial with 517 adult participants who had experienced gout attacks within the previous 12 months. One group received guidance from nurses who explained the condition and adjusted their medication to meet the target level; the other group continued to receive standard care from general practitioners. After two years, 95% of the intervention group had blood uric acid levels below 360 µmol/L (6 mg/dL), compared to just 30% of the control group. This represents a 3.18-fold increase in the likelihood of success (RR 3.18, 95% CI 2.42–4.18; this range indicates statistical reliability), with a P-value of less than 0.0001. Secondary outcomes such as attack frequency, presence of tophi, and quality of life also improved significantly in the intervention group. Each additional year of healthy life, adjusted for quality of life, cost approximately £5,066. A follow-up survey of 438 participants yielded a response rate of 82%; median attack frequency was 0 per year in the target-achieving group versus 1 per year in the control group (P<0.001). The proportion of participants still taking uric acid-lowering drugs was 1.19 times higher in the intervention group (adjusted RR 1.19, 1.09–1.30). The 2020 American College of Rheumatology guidelines strongly recommend starting such treatment for three groups: those with visible tophi, those showing bone damage on imaging, and those experiencing at least two attacks per year. The recommended approach involves continuous monitoring and dosage adjustment until levels drop below 6 mg/dL; allopurinol is the first-line choice, especially for patients with stage 3 or higher chronic kidney disease, with an initial dose of no more than 100 mg per day. Anti-inflammatory preventive drugs must also be taken for at least 3 to 6 months. Observational data from the same study showed that after successful long-term control, 87% of patients who discontinued medication still maintained levels below 7 mg/dL; however, only 13% remained free of attacks over a five-year follow-up period. Dietary interventions have limited impact: abstaining from alcohol lowers levels by just 1.6 mg/dL, while one serving of beer raises them by 0.16 mg/dL. Healthier diets such as Mediterranean or DASH diets produce even smaller effects.

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；中华医学会内分泌学分会 (2020). 中国高尿酸血症与痛风诊疗指南(2019). 中华内分泌代谢杂志, 36(1), 1-13. https://doi.org/10.3760/cma.j.issn.1000-6699.2020.01.001

Han Chinese individuals should consider testing for HLA-B*5801 before starting allopurinol. This gene variant occurs in 7.4% of Han Chinese, Korean, and Thai populations, compared to only 0.7% of white and Hispanic individuals. Asians and African Americans face a threefold higher risk of allopurinol hypersensitivity syndrome, a potentially fatal condition involving widespread skin peeling; thus, the 2020 American College of Rheumatology guidelines advise genetic testing for these groups. Initiating uric acid-lowering therapy may temporarily increase attack frequency, so guidelines mandate concurrent use of anti-inflammatory preventive drugs for the first 3 to 6 months. Stopping medication due to increased pain is a common mistake; instead, additional anti-inflammatory drugs should be used as directed. Target levels of <6 mg/dL roughly correspond to 360 µmol/L, though Chinese medical reports typically use µmol/L units. Elevated uric acid levels without any prior attacks represent a different clinical scenario, discussed in Section 6, Item 19. Further details on sugary drinks and alcohol can be found in Section 2, Items 7 and 20.