Treatment of Hyperuricemia in CKD

Treatment of Hyperuricemia in CKD

In general, xanthine oxidase inhibitors such as allopurinol or febuxostat are the preferred agents to decrease uric acid levels due to their effectiveness in both overproducers and undersecretors of uric acid. Allopurinol is metabolized by xanthine oxidase to oxypurinol, and both substrates act to inhibit xanthine oxidase.[65] Patients with CKD may be at increased risk of toxicity with allopurinol (eg, rash, gastrointestinal intolerance, leukopenia, and severe hypersensitivity reaction) because oxypurinol is cleared by the kidney.[66] In addition, some investigators have suggested that insufficient dosing of allopurinol in patients with CKD and gout leads to undertreatment.[67] Thus, it is widely recommended to start with low dosages of allopurinol in patients with CKD and slowly titrate it to an effective dose. Febuxostat, a nonpurine selective xanthine oxidase inhibitor, has been shown to be safe and effective for decreasing serum uric acid levels[68] and represents a pharmacologic alternative to allopurinol in hyperuricemic patients who are unable to tolerate allopurinol.