Table 2a. Core Recommendations for the Use of
Allopurinol ULT in Gout
Allopurinol
Starting dosage should be ≤100 mg/day for any patient, and start at ≤50 mg/day in stage 4
or worse CKD. (B)
Gradually titrate maintenance dose upward every 2–5 weeks to appropriate maximum dose
in order to reach the target serum urate. (C)
Dose can be titrated gradually and slowly above 300 mg daily, even with renal impairment,
as long as it is accompanied by adequate patient education and monitoring for drug toxicity
(e.g., pruritus, rash, elevated hepatic transaminases). (B)
Prior to initiation, consider HLA–B*5801 in selected patients with high risk for severe
allopurinol hypersensitivity reaction (e.g., Koreans with stage 3 or worse CKD and Han
Chinese and ai irrespective of renal function). (A)
Table 2b. Core Recommendations for the Use of
Uricosuric ULT in Gout
Uricosuric therapy
Probenecid is the first choice among uricosuric agents for ULT monotherapy.
a
(B)
In gout patients with a creatinine clearance <50 mL/minute, probenecid is not
recommended as first-line ULT monotherapy. (C)
Use of agents with clinically significant uricosuric effects other than probenecid, such as
fenofibrate and losartan, can be therapeutically useful as components of a comprehensive
ULT strateg y. (B)
History of urolithiasis contraindicates first-line uricosuric urate-lowering monotherapy. (C)
Urinary uric acid should be measured before initiation of uricosuric ULT. (C)
Elevated urine uric acid indicative of uric acid overproduction contraindicates uricosuric
ULT. (C)
Continue to monitor urinary uric acid during uricosuric ULT. (C)
Consider urine alkalinization (e.g., with potassium citrate) with monitoring of urine pH in
addition to increased fluid intake, as a risk management strateg y for urolithiasis. (C)
a
Probenecid is NOT recommended as a first line or alternative first line ULT agent if the
CrCl is <50. (C)
