10.1.4.2 Prophylaxis of gout

It is important to distinguish drugs used for the treatment of acute attacks of gout from those used in the long-term control of the disease. The latter exacerbate and prolong the acute manifestations if started during an attack.

ChoiceDrugDosage
1st choiceAllopurinol tablets 100mg, 300mgDose:
Initially 100mg daily, increasing by 100mg increments every few weeks, adjusted as necessary for renal function, until the therapeutic target (plasma urate <300micromoL/L) is reached (maximum dose 900mg) ; doses over 300mg daily given in divided doses. Preferably take after food

2nd choice
(if inadequate response to maximum dose of allopurinol (900mg) or not tolerated

Febuxostat f/c tablets 80mg, 120mgDose:
80mg once daily, if after 4-6 weeks serum uric acid greater than 300 micromol/L) increase to 120mg once daily (plasma urate should be maintained below 300 micromoL/L) provided compliance has been good

Prescribing Notes

  • Patients with gout often have increased cardiovascular morbidity and mortality. Underlying conditions such as hypertension, diabetes or renal impairment should be identified and the patient’s overall cardiovascular risk assessed.
  • In uncomplicated gout, uric acid lowering drug therapy should be started if a second attack or further attacks occur within 1 year.
  • Consider prophylaxis in patients who have had an attack of gout and who need high dose diuretics and monitor urate in patients with renal insufficiency.
  • Neither allopurinol nor febuxostat should be started during an acute attack, as they will increase its intensity. Usually wait 4 to 6 weeks after an acute episode before starting treatment.
  • Treatment should be continued indefinitely to prevent further attacks of gout by correcting the hyperuricaemia. These drugs must not be stopped during any acute gout flare ups.
  • Colchicine 0.5 mg twice daily should be co-prescribed following initiation of treatment with allopurinol or uricosuric drugs, and continued for up to 6 months. In patients who cannot tolerate colchicine, a NSAID can be substituted provided that there are no contra-indications. The NSAID should be continued until symptom control is achieved and the patient is stabilised
  • Analgesic doses of aspirin should be avoided. Low dose aspirin has the potential to precipitate gout; it should be reviewed and continued if indicated.
  • Allopurinol can cause rashes, including the rare and potentially life-threatening Allopurinol Hypersensitivity Syndrome (AHS).
  • The dose of allopurinol should be reduced in renal impairment:
    GFR 20 to 50mL/min: 200 to 300mg daily
    GFR 10 to 20mL/min: 100 to 200mg daily
    GFR < 10mL/min: 100mg daily or 100mg on alternate days
  • Febuxostat can be considered for patients who are intolerant of allopurinol or for whom allopurinol is contra-indicated. See NICE TA 164. Use with caution if eGFR <30mL/min
  • Allopurinol and febuxostat have important interactions with azathioprine and mercaptopurine and should not be prescribed together.

Recommendations for diet, lifestyle modification and non-pharmacological modalities of therapy

  • Refer to UK Gout Society Diet Factsheet for advice on healthy lifestyle choices in gout.

Caution

  • The MHRA drug safety update June 2012 detailed that febuxostat (Adenuric®) should be stopped if signs or symptoms of serious hypersensitivity (e.g. serious skin reactions or systemic hypersensitivity ) occur.