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HYPERURICEMIA, a serum uric acid level greater than 6. 2 mg/dL in female patients and greater than 8.0 mg/dL in male patients. Hyperuricemia may be classified as primary, which refers to disease states in which elevated serum urate levels are the result of inherently disordered uric acid metabolism not associated with an underlying disease state. Secondary hyperuricemia refers to an elevated serum uric acid level that is the result of an underlying disease state (renal failure, hematologic malignancies, hypothyroidism, alcoholism, etc.). Transient hyperuricemia is commonly seen with dehydration, and the abnormality is rapidly reversible with fluid resuscitation.

Hyperuricemia may result from uric acid overproduction or decreased renal excretion. Uric acid underexcretion is seen in approximately 90% of patients with primary hyperuricemia. Decreased renal excretion of uric acid is a side effect of certain medications to include cyclosporine, diuretics, pyrazinamide, ethambutol, niacin, and low-dose salicylates. At high doses, salicylates suppress renal tubular uric acid reabsorption and therefore result in hyperuricosuria, with resultant reduced serum uric acid levels.

The most common symptoms of hyperuricemia are gout, tophi, and nephrolithiasis (uric acid and calcium oxalate stones). A low urinary pH favors uric acid nephrolithiasis formation. In fact, asymptomatic hyperuricemia is not an indication to initiate therapy. Once patients manifest recurrent gouty arthritis attacks, tophi, or nephrolithiasis, treatment for hyperuricemia should be initiated. When certain tumors are treated, tumor lysis syndrome with resultant hyperuricemia can be a complication. Xanthine oxidase prophylaxis may be prescribed if tumor lysis syndrome is anticipated.

Symptomatic hyperuricemia may be treated with xanthine oxidase inhibitors (allopurinol or febuxostat), probenecid, or sulfinpyrazone. The xanthine oxidase inhibitors are used far more commonly than probenecid and sulfinpyrazone. The dosage of the therapeutic agent should be titrated against the serum uric acid level until it is less than 6.0 mg/dL and then continued either indefinitely or until uric acid levels are expected to decrease on their own after chemotherapy. Pegloticase is an intravenous agent used to lower uric acid levels in cases of tophaceous gout. If the patient with gout has a concomitant condition requiring ARB therapy (CHF, hypertension, proteinuria) or a fibrate (dyslipidemia) then either losartan or fenofibrate may used as they possess uricosuric effects and thus serve to lower the serum uric acid.