High uric acid but no gout, should I take medicine?

*It is only for medical professionals to read for reference.
Is it necessary to take medicine for high monouric acid? Hyperuricemia is a metabolic syndrome caused by a disorder of purine metabolism and has become the "fourth major metabolic disease" after diabetes
.

At present, the prevalence of hyperuricemia in China is as high as 13.
3%, and the gout population accounts for 1%-3% of the total population
.

Clinically, hyperuricemia with only elevated blood uric acid without gout symptoms is defined as asymptomatic hyperuricemia
.

Studies have shown that
.

Only one-third of patients with asymptomatic hyperuricemia will eventually progress to gout, and some patients may not cause gout attacks for life
.

Many evidences indicate that hyperuricemia and gout are independent risk factors for chronic kidney disease, hypertension, cardiovascular and cerebrovascular diseases and diabetes, and are independent predictors of premature death
.

Therefore, exploring the target population of precise uric acid-lowering therapy and preventing gout attacks has become a hot spot in the medical community
.

At present, there are still great controversies about the treatment of asymptomatic hyperuricemia in domestic and foreign guidelines
.

Starting from the most authoritative guide at home and abroad, this article discusses the target population of asymptomatic hyperuricemia for precise uric acid lowering treatment
.

How does the guideline define hyperuricemia? With reference to the "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019 Edition)", hyperuricemia is defined as: regardless of men and women, 2 fasting blood uric acid> 420 μmol/L on different days is considered hyperuricemia
.

Among them, hyperuricemia without clinical symptoms and signs of gout is defined as asymptomatic hyperuricemia
.

What are the complications of hyperuricemia? Hyperuricemia and gout are diseases closely related to life>
.

The specific hazards are shown in Figure 1: Figure 1: The hazards of hyperuricemia How are gout and hyperuricemia clinically staged? In the past, hyperuricemia and gout were considered to have four stages: asymptomatic hyperuricemia, acute gouty arthritis, critical gout, and chronic gout
.

Although this staging system describes the symptoms of gout, it does not capture the key aspects of the pathophysiological basis of the disease
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Imaging imaging and microscopy studies have shown that monosodium urate (MSU) crystals are present in the joints of asymptomatic hyperuricemia patients, which are not in the traditional staging system
.

More and more scholars recognize that hyperuricemia and gout are chronic and continuous pathophysiological processes, and the boundary between the two has gradually become blurred
.

Therefore, Dalbeth N et al.
redefines the clinical staging system for gout and hyperuricemia, as shown in Figure 2 and Table 1: Figure 2: Classification system of hyperuricemia and gout Table 1: Classification of hyperuricemia and gout What are the benefits and risks of systemic uric acid-lowering therapy? For patients with gout, there are clear indications for uric acid lowering treatment
.

The basic principle of uric acid-lowering therapy is to fully reduce uric acid to dissolve MSU crystals in the body
.

Studies have shown that continuous reduction of blood uric acid to 6.
0 mg/dl (357 µmol/L) can cause the dissolution of MSU crystals, the reduction of the frequency of gout attacks, and the dissolution of MSU crystals
.

However, gout patients who have not undergone uric acid-lowering treatment can lead to complications such as progressive MSU crystal deposition, joint erosion, and tophi
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Therefore, uric acid-lowering treatment has obvious benefits
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Uric acid-lowering drugs, like all drugs, also have the risk of adverse reactions, especially allopurinol hypersensitivity syndrome
.

Considering that adverse reactions are relatively rare, the benefits of lowering uric acid in the treatment of gout patients outweigh the potential risks
.

However, the probability of developing gout in patients with asymptomatic hyperuricemia and asymptomatic hyperuricemia with MSU crystal deposition is unclear, which means that the prognosis of uric acid-lowering therapy for these hyperuricemia populations is unclear
.

Since there is no large sample of clinical research evidence to support it, it is difficult to accurately assess the risk-benefit ratio of uric acid-lowering treatment
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However, as mentioned earlier, there is a close relationship between hyperuricemia and hypertension, hyperglycemia, cardiovascular and cerebrovascular diseases and chronic kidney disease
.

Some small clinical trials have also shown that uric acid-lowering therapy is related to the efficacy of hypertension, cardiovascular and cerebrovascular diseases and chronic kidney disease in patients with asymptomatic hyperuricemia
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And it reduces the patient's blood uric acid level, its blood pressure and blood sugar are significantly reduced, and the risk of cardio-cerebral angiogenesis is also significantly reduced
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What do domestic and foreign guidelines say about the treatment of asymptomatic hyperuricemia? At present, there is a lot of controversy about the treatment strategy of asymptomatic hyperuricemia at home and abroad
.

Most European and American countries do not recommend the beginning of uric acid lowering treatment for asymptomatic hyperuricemia, while most Asian countries hold a positive attitude
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The "Practice Guidelines for Patients with Hyperuricemia/Gout in China (2020)" and "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019 Edition)" point out that it is recommended to start uric acid lowering drugs for asymptomatic hyperuricemia patients who meet the following conditions Treatment: blood uric acid level ≥540μmol/L; blood uric acid level ≥480μmol/L, and one of the following complications: hypertension, abnormal lipid metabolism, diabetes, obesity, stroke, coronary heart disease, cardiac insufficiency, uric acid kidney Stone disease, renal impairment [≥chronic kidney disease (CKD) stage 2]
.

According to the 2020 American College of Rheumatology (ACR) Gout Management Guidelines, it is not recommended to initiate uric acid-lowering treatment for patients with asymptomatic hyperuricemia
.

For most patients with asymptomatic hyperuricemia (including patients with CKD, cardiovascular disease, kidney stones or hypertension), since it is unlikely to develop gout, the benefits of uric acid-lowering therapy cannot exceed the potential treatment costs or risks
.

Even if MSU crystal deposits are found in ultrasound and DECT, uric acid-lowering treatment is not recommended
.

Summary: Does asymptomatic hyperuricemia need uric acid lowering treatment? In recent years, more and more researchers have realized that the management of asymptomatic hyperuricemia patients should pay attention to continuous, long-term, and even lifelong monitoring and management of the disease like other metabolic diseases
.

In conclusion, patients with asymptomatic hyperuricemia should consider uric acid-lowering therapy, especially those with higher blood uric acid levels and those with MSU crystal deposits
.

References: [1].
Guidelines for the diagnosis and treatment of hyperuricemia and gout in China (2019)[J].
Chinese Journal of Endocrinology and Metabolism,2020,36(1):1-13.
DOI:10.
3760/cma.
j.
issn.
1000 -6699.
2020.
01.
001.
[2].
Dalbeth N, Stamp L.
Hyperuricaemia and gout: time for a new staging system?[J].
Ann Rheum Dis, 2014,73(9):1598-1600.
DOI:10.
1136/annrheumdis -2014-205304.
[3].
Stamp L, Dalbeth N.
Urate-lowering therapy for asymptomatic hyperuricaemia: A need for caution[J].
Semin Arthritis Rheum, 2017,46(4):457-464.
[4].
FitzGerald JD, Dalbeth N, Mikuls T, et al.
2020 American College of Rheumatology Guideline for the Management of Gout[J].
Arthritis Rheumatol, 2020,72(6):879-895.