10.1.4 Gout and cytotoxic-induced hyperuricaemia

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 500 micrograms (£1.15 = 12 tablets)

Indications and dose

Notes

  1. COVID-19: Colchicine should NOT be used in the management of COVID-19 positive patients other than in the context of a trial, or unless there is an additional licensed indication for its use. For more information, see the CAS alert (issued 12 February 2021).
  2. MHRA Drug Safety Update (November 2009): Colchicine: extremely toxic in overdose.
    1. Colchicine has a very narrow therapeutic-toxic window and is extremely toxic in overdose.
    2. Patients at particular risk of toxicity are those with renal or hepatic impairment, gastrointestinal or cardiac disease, and patients at extremes of age
    3. The symptoms of overdose are often delayed.
    4. All patients, even in the absence of early symptoms, should be referred for immediate medical assessment
  3. 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 (£3.44 = 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

  1. In renal impairment, lower dose required (see SPC)
  2. Ensure adequate fluid intake (2-3 litres/day)
  3. Hypersensitivity reactions are common. Stop treatment if a rash develops
  4. 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
  5. 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 (£24.36 = 80mg daily)

Indications and dose

Notes

  1. Prophylaxis for gout flares with NSAID or colchicine is required for six months on initiation of treatment
  2. NICE TA164: 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 (December 2008)
  3. MHRA Drug Safety Update (June 2012): Serious hypersensitivity reactions
    1. Febuxostat treatment should be stopped immediately if signs or symptoms of serious hypersensitivity reactions occur – early withdrawal is associated with a better prognosis.
    2. If a patient has ever developed a hypersensitivity reaction with febuxostat, including Stevens-Johnson syndrome, febuxostat must not be re-started at any time.
    3. Most cases of hypersensitivity to febuxostat occur during the first month of treatment.
    4. Patients should be advised of signs and symptoms of severe hypersensitivity or Stevens-Johnson syndrome.
    5. A prior history of hypersensitivity to allopurinol and/or renal disease may indicate potential hypersensitivity to febuxostat.
  4. Treatment in patients with ischaemic heart disease or congestive heart failure is not recommended.
  5. Efficacy and safety has not been evaluated in patients with severe renal or hepatic impairment.
  6. MHRA Drug Safety Update (July 2019): Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease (for example, myocardial infarction, stroke, or unstable angina)
    1. avoid treatment with febuxostat in patients with pre-existing major cardiovascular disease, unless no other therapy options are appropriate
Lesinurad

NICE TA506: Lesinurad is not recommended with a xanthine oxidase inhibitor for treating hyperuricaemia in adults with gout whose serum uric acid is above the target level despite an adequate dose of a xanthine oxidase inhibitor alone (February 2018).

Drugs used in the treatment of cytotoxic-induced hyperuricaemia

Rasburicase
  • Powder and solvent for solution for infusion 1.5mg, 7.5mg vials

Notes

  1. 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.

 

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