Prescribing notes
- Prescribe as per NICE NG219 Gout: diagnosis and management recommendations. See NICE visual summaries and also NICE CKS: Gout and BMJ Gout: diagnosis and management – summary of NICE guidance.
- Offer allopurinol first line in people who have major cardiovascular disease.
- Assess lifestyle and comorbidities (including cardiovascular risk factors and CKD).
- ULT should not be started during an acute attack, as it will increase its intensity. Usually wait at least 2 to 4 weeks after an acute episode before starting ULT. Once ULT is commenced it is continual (typically lifelong) and must not be stopped during acute gout flares.
- Discuss the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT:
- For people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached.
- If colchicine is contraindicated or not suitable, consider a low dose NSAID or a low dose oral corticosteroid (note off-label use of NSAID and corticosteroids). Consider adding a proton pump inhibitor, taking into account individual risk factors
- Analgesic doses of aspirin should be avoided. Low dose aspirin has the potential to precipitate gout; it should be reviewed and continued if indicated.
Cautions
- Allopurinol can cause rashes, including the rare and potentially life-threatening Allopurinol Hypersensitivity Syndrome (AHS). Monitor closely for hypersensitivity syndrome when therapy is initiated.
- Caution is required if prescribing febuxostat in patients with pre-existing major cardiovascular disease, particularly in those with evidence of high urate crystal and tophi burden or those initiating ULT- see MHRA.
- Febuxostat should be stopped if signs or symptoms of serious hypersensitivity (e.g. serious skin reactions or systemic hypersensitivity ) occur, see MHRA.
Renal Impairment
- Allopurinol should be used with caution (risk of accumulation) – refer to BNF re dose adjustments. The British Society of Rheumatology (BSR) give further recommendations on starting doses according to GFR to reduce the risk of allopurinol hypersensitivity– refer to table 2 in BSR guideline
- Febuxostat requires no dose adjustment in mild or moderate renal impairment. Caution in severe renal impairment (creatinine clearance <30mL/min).