The FDA has approved Duzallo (Ironwood), a fixed-dose combination of the uric acid transporter 1 (URAT1) inhibitor lesinurad (Zurampic)1 and the xanthine oxidase inhibitor allopurinol (Zyloprim, and generics), for once-daily treatment of gout-associated hyperuricemia in patients who have not achieved target serum uric acid levels with allopurinol alone.
Recent guidelines offer conflicting views on the benefits of monitoring serum uric acid levels and the appropriate use of urate-lowering therapy in patients with gout,2-4 but most expert clinicians still treat gout-associated hyperuricemia initially with a xanthine oxidase inhibitor such as allopurinol or febuxostat (Uloric) with the goal of reducing the serum uric acid level to <6.0 mg/dL (and preferably to <5.0 mg/dL). The uricosuric drug probenecid can be used as add-on therapy if target serum uric acid levels are not reached with a xanthine oxidase inhibitor alone or as initial therapy in patients who cannot tolerate a xanthine oxidase inhibitor. Probenecid is less effective in patients with renal insufficiency (eGFR≤30 mL/min). Pegloticase (Krystexxa), a pegylated urate oxidase administered intravenously, is highly effective, but it is very expensive and can cause serious adverse effects, including anaphylaxis; it should be reserved for patients with severe tophaceous gout that has not responded to treatment with both a xanthine oxidase inhibitor and a uricosuric drug.5
Lesinurad/Allopurinol (Duzallo) for Gout-Associated Hyperuricemia. JAMA. 2018;319(2):188–189. doi:10.1001/jama.2017.20189
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