According to an editorial, these findings highlight the value of judicious, guideline-based hyperuricaemia management throughout the world. The author notes that in US, allopurinol hypersensitivity occurs one-fourth as in current study, which is in part a matter of genetic epidemiology: the HLA-B*5801 haplotype is strongly associated with allopurinol hypersensitivity and is prevalent in Han Chinese individuals, and the population of Taiwan is 95% Han Chinese.3 She discusses how to prevent allopurinol hypersensitivity in an ethnically diverse population and concludes that this study is a reminder of importance of following treatment guidelines. She recommends that based on US guidance, firstly use of lifestyle changes and prescription of urate-lowering therapy only for those with frequent gout attacks (>2 per year), tophaceous gout, comorbid stage 2 to 5 chronic kidney disease, or urolithiasis. Allopurinol should not be prescribed for asymptomatic hyperuricemia. Secondly, all Thai and Han Chinese patients, as well as Korean patients with kidney disease, should be screened for the HLA-B*5801 haplotype prior to allopurinol initiation. If the results of the test are positive or the patients are otherwise at high risk, consider an alternative agent. Lastly allopurinol therapy should be started at no more than 100 mg/d and the dose titrated slowly.
British Society of Rheumatology (BSR) guidance from 2007 does not address ethnic populations. It makes the following recommendations on management of recurrent, intercritical and chronic gout:
• The plasma urate should be maintained below 300 micromol/L
• In uncomplicated gout uric acid lowering drug therapy should be started if a second attack or further attacks occur within 1 year.
• Uric acid lowering drug therapy should also be offered to patients with tophi, patients with renal insufficiency, patients with uric acid stones and gout and to patients who need to continue treatment with diuretics.
• Commencement of uric acid-lowering drug therapy should be delayed until 1–2 weeks after inflammation has settled.
• Initial long-term treatment of recurrent uncomplicated gout normally should be with allopurinol starting in a dose of 50–100 mg/day and increasing by 50–100 mg increments every few weeks, adjusted if necessary for renal function, until the therapeutic target is reached (maximum dose 900 mg)
• Uricosuric agents can be used as second-line drugs in patients who are under-excretors of uric acid and in those resistant to, or intolerant of, allopurinol.