Long-term control of gout (Formulary)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Consider allopurinol for long-term control in patients with acute attacks of gouty arthritis:

  • with more than one episode in a year
  • if attempts to reduce risk factors have failed
  • with tophi, clinical or radiological signs of chronic gouty arthritis
  • with recurrent uric acid renal stones.

Co-prescription with NSAIDs or colchicine 500 micrograms twice daily is often required for 6 months to 1 year. Febuxostat may be used for those with intolerance to allopurinol or mild to moderate renal impairment (caution with febuxostat if eGFR less than 30mL/min/1·73m2).

Refer to Management of gout guidance on the Rheumatology home page on the intranet.

ALLOPURINOL - (First line)

Therapy notes

  • Monitor renal function in ‘at risk’ patients.
  • Do not use allopurinol in patients with eGFR <30mL/min/1·73m2.

Formulation and dosage details

Formulation:

Tablets 100mg, 300mg

Dosage:

Introduce allopurinol after the acute attack has settled, starting with a dose of 100mg/day after food, adjusted at fortnightly intervals to achieve serum urate less than 0·36 mmol/L.

Usual maintenance dose: in mild conditions, 100 to 200mg daily; in moderately severe conditions, 300 to 600mg daily; in severe conditions, 700 to 900mg daily. 

Doses of over 300mg daily should be given in divided doses of up to 300mg. 

FEBUXOSTAT - (Second line)

Therapy notes

MHRA advice: Febuxostat: updated advice for the treatment of patients with a history of major cardiovascular disease (May 2023) (www.gov.uk). 
MHRA advice: Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease (July 2019) (www.gov.uk). 
MHRA advice: Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease (December 2014) (www.gov.uk). 

  • may be used when treatment with allopurinol is inadequate, not tolerated or contra-indicated
  • aim to achieve serum urate levels less than 0·36mmol/L
  • consider for patients with mild to moderate renal impairment (use febuxostat with caution if eGFR less than 30mL/min/1·73m2)
  • avoid in patients with ischaemic heart disease or congestive heart failure
  • check liver function prior to initiation and every 6 months thereafter
  • febuxostat can cause serious skin conditions, see www.mhra.gov.uk.

Formulation and dosage details

Formulation:

Tablets 80mg, 120mg

Dosage:

Initially 80mg once daily, if after 2 to 4 weeks the serum uric acid is greater than 0·36mmol/L then increase to 120mg once daily.

As per SMC 1153/16: the prevention and treatment of hyperuricaemia in adult patients undergoing chemotherapy for haematologic malignancies at intermediate to high risk of Tumour Lysis Syndrome (TLS).

SMC restriction: prevention of hyperuricaemia in adult patients at intermediate risk of TLS in
whom allopurinol is either unsuitable or contraindicated, such as:

  • Those intolerant of allopurinol
  • Those in whom allopurinol is contraindicated, eg patients with renal impairment.

Editorial Information

Document Id: F279