For the formulary entry on the management of gout see Management of Gout and cytotoxic-induced hyperuricaemia.

Drugs used for the management of gout not listed below:

• NSAID {See section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)}
• Prednisolone (See section 6.3.2 Glucocorticoid therapy)

Drugs used in the treatment of acute gout

Colchicine

• Tablets 500micrograms (£0.27 = 12 tablets)

Indications

• Acute gout
• Short-term prophylaxis of gout during initial therapy with allopurinol and uricosuric drugs

Dose

• Acute gout, 500micrograms 2–4 times daily until symptoms relieved, maximum 6mg per course; course not to be repeated within 3 days
• Prevention of gout attacks during initial treatment with allopurinol or uricosuric drugs, 500micrograms twice daily whilst hyperuricaemia is corrected

Notes

1. MHRA Drug Safety Update (December 2014): 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.
2. 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

• Prophylaxis of gout and of uric acid and calcium oxalate renal stones
• Prophylaxis of hyperuricaemia associated with cancer chemotherapy

Dose

• 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 (£2.68 = 80mg daily)

Indications

• Chronic hyperuricaemia in gout

Dose

• 80mg once daily; if after 2–4 weeks serum uric acid greater than 6mg/100 mL, increase to 120mg once daily

Notes

1. Prophylaxis for gout flares with NSAID or colchicine is required for six months on initiation of treatment.
2. 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.
3. MHRA advice Serious hypersensitivity reactions (June 2012)
   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 (May 2023): : updated advice for the treatment of patients with a history of major cardiovascular disease 
   1. 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.
   2. Following initiation of febuxostat, prescribers should titrate the febuxostat dose to minimise gout flares and inflammation.
   3. 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 vials 1.5mg, 7.5mg

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.