Don’t start taking uric‑acid‑lowering drugs just because a checkup shows high uric acid but you’ve never had symptoms

19. Don’t start taking uric‑acid‑lowering drugs just because a checkup shows high uric acid but you’ve never had symptoms

Cost: There’s no cost at all; you also avoid long‑term medication expenses, regular follow‑ups, and the risks linked to unnecessary drug use.

In plain terms: People whose uric acid levels are high but who’ve never had gout attacks or tophus deposits mainly gain peace of mind from taking uric‑acid‑lowering drugs. According to calculations by the American College of Rheumatology, you’d need to treat 24 people for three full years just to prevent a single gout episode. These drugs also won’t protect your kidneys; in randomized trials the rate of kidney‑function decline was identical in patients taking them and those on a placebo. What truly helps is keeping weight, alcohol, and sugary drinks in check — and only treating gout after an actual attack occurs.

Benefit: The 2020 gout guidelines from the American College of Rheumatology address asymptomatic hyperuricemia, defined as blood uric‑acid levels above 6.8 mg/dL in people who’ve never had gout or tophus. Under certain conditions the guidelines advise against initiating any uric‑acid‑lowering therapy — drugs such as allopurinol, febuxostat, or probenecid. Evidence supporting this recommendation is rated “high.” A footnote clarifies that, based on attributable risk, 24 patients must be treated for three years to prevent one gout episode. The CKD‑FIX trial enrolled 363 participants with stage 3 or 4 chronic kidney disease; they had no gout history but faced a higher risk of worsening kidney function. One group received 100–300 mg of allopurinol daily while the other got a placebo; after 104 weeks the annual change in eGFR — a key kidney‑function marker measured in mL/min/1.73 m² — was –3.33 (95 % CI –4.11 to –2.55) in the drug group versus –3.23 (–3.98 to –2.47) in the placebo group. The difference between groups was –0.10 (–1.18 to 0.97), with a P‑value of 0.85, meaning kidney‑function decline proceeded at the same pace. Serious adverse events occurred in 46 % of patients on allopurinol versus 44 % on placebo. The PERL trial involved 530 type 1 diabetics with early‑to‑moderate diabetic kidney disease; after three years of allopurinol therapy the drug was withdrawn for two months to gauge its effect. Allopurinol lowered blood uric‑acid from 6.1 mg/dL to 3.9 mg/dL, yet after discontinuation the eGFR difference between groups narrowed to just 0.001 mL/min/1.73 m² (95 % CI –1.9 to 1.9, P = 0.99). Moreover, urinary albumin excretion rose 40 % (range 0–80 %) in the allopurinol group. The apparent “benefit” stems largely from the intuitive notion that any elevated marker warrants medication.

Evidence grade: A

Sources: 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 (Table 1 and footnotes). <https://doi.org/10.1002/acr.24180>; Badve SV, Doria A, Galecki AT, Spino C, et al. (2020). Serum Urate Lowering with Allopurinol and Kidney Function in Type 1 Diabetes. New England Journal of Medicine, 382(26), 2493-2503. <https://doi.org/10.1056/NEJMoa1916624>

Notes: This recommendation specifically discourages lifelong uric‑acid‑lowering therapy in people who’ve never experienced gout; it does not imply that high uric‑acid levels are harmless. The same guidelines outline exceptions where treatment may be warranted: first‑time gout attacks accompanied by stage 3 or higher chronic kidney disease, blood uric‑acid levels exceeding 9 mg/dL (≈535 µmol/L), or a history of uric‑acid kidney stones. Those who’ve already had gout attacks, have tophus deposits, or show bone erosion on imaging should indeed start medication — see Section 16, Item 9 for details. Roughly 7.4 % of Han Chinese carry the HLA‑B*5801 genotype, compared to just 0.7 % of Caucasians; carriers face a markedly higher risk of life‑threatening hypersensitivity reactions, with Asian patients three times more prone to severe skin syndromes than white patients. Given this risk, it’s prudent to avoid allopurinol unless absolutely necessary; testing for the HLA‑B*5801 variant before prescribing is advisable, as noted in Section 16, Item 9. The kidney studies involved patients with chronic kidney disease or type 1 diabetes, so their findings shouldn’t be extrapolated to suggest that high uric‑acid levels are completely benign for all kidneys. They merely refute the claim that uric‑acid‑lowering drugs protect kidney function.