For the formulary entry on the management of gout see Management of Gout.
Drugs used for the management of gout not listed below:
Drugs used in the treatment of acute gout
Colchicine
- Tablets 500micrograms (£0.27 = 12 tablets)
Indications and dose
Notes
- MHRA Drug Safety Update (November 2009): Colchicine: extremely toxic in overdose
- Colchicine has a very narrow therapeutic-toxic window and is extremely toxic in overdose.
- Patients at particular risk of toxicity are those with renal or hepatic impairment, gastrointestinal or cardiac disease, and patients at extremes of age.
- The symptoms of overdose are often delayed.
- All patients, even in the absence of early symptoms, should be referred for immediate medical assessment.
- Gastrointestinal side effects are common especially at high doses.
Drugs used in the long-term treatment of gout
Do not initiate until an acute attack has settled, normally 1-2 weeks after.
Allopurinol
- Tablets 100mg, 300mg (£1.50 = 200mg daily)
Indications and dose
- Prophylaxis of gout and of uric acid and calcium oxalate renal stones and Prophylaxis of hyperuricaemia associated with cancer chemotherapy
- Initially 100mg daily, preferably after food, then adjusted according to plasma or urinary uric acid concentration
- Usual maintenance dose in mild conditions 100–200mg daily, in moderately severe conditions 300–600mg daily, in severe conditions 700–900mg daily; doses over 300mg daily given in divided doses
Notes
- In renal impairment, lower dose required (see SPC).
- Ensure adequate fluid intake (2-3 litres/day).
- Hypersensitivity reactions are common. Stop treatment if a rash develops.
- Allopurinol has a serious drug interaction with azathioprine and mercaptopurine. There may also be unpredictable interactions with many other medications, e.g. warfarin. Refer to manufacturers SPC and BNF for further details.
- Administer prophylactic NSAID (not aspirin or salicylates) or colchicine until at least 1 month after hyperuricaemia corrected (usually for first 3 months) to avoid precipitating an acute attack.
Febuxostat
- Tablets 80mg, 120mg (£2.68 = 80mg daily)
Indications and dose
Notes
- Prophylaxis for gout flares with NSAID or colchicine is required for six months on initiation of treatment.
- Febuxostat (Adenuric) is recommended as an option for the management of chronic hyperuricaemia in gout only for people who are intolerant of allopurinol or for whom allopurinol is contraindicated.
- MHRA Drug Safety Update (June 2012): Serious hypersensitivity reactions
- Febuxostat treatment should be stopped immediately if signs or symptoms of serious hypersensitivity reactions occur – early withdrawal is associated with a better prognosis.
- If a patient has ever developed a hypersensitivity reaction with febuxostat, including Stevens-Johnson syndrome, febuxostat must not be re-started at any time.
- Most cases of hypersensitivity to febuxostat occur during the first month of treatment.
- Patients should be advised of signs and symptoms of severe hypersensitivity or Stevens-Johnson syndrome.
- A prior history of hypersensitivity to allopurinol and/or renal disease may indicate potential hypersensitivity to febuxostat.
- Treatment in patients with ischaemic heart disease or congestive heart failure is not recommended.
- Efficacy and safety has not been evaluated in patients with severe renal or hepatic impairment.
- MHRA Drug Safety Update (May 2023): Febuxostat: updated advice for the treatment of patients with a history of major cardiovascular disease
- In patients with pre-existing major cardiovascular diseases, febuxostat therapy should be used cautiously, particularly in those with evidence of high urate crystal and tophi burden or those initiating urate-lowering therapy.
- Following initiation of febuxostat, prescribers should titrate the febuxostat dose to minimise gout flares and inflammation.
- Note that clinical guidelines for gout (see, for example, NICE guideline 219 – Gout: diagnosis and management) recommend that allopurinol should be offered as first-line treatment for people with gout who have major cardiovascular disease.
Drugs used in the treatment of cytotoxic-induced hyperuricaemia
Rasburicase
- Powder and solvent for solution for infusion 1.5mg, 7.5mg vials
Notes
- Indicated only for the prophylaxis and treatment of acute hyperuricaemia, before and during initiation of chemotherapy, in patients with haematological malignancy and high tumour burden at risk of rapid lysis.