Rheumatology Guideline for the Management of Gout
(Part 6)
We now continue our series where we discuss the guidelines in the management of gout.
We start with allopurinol desensitization which is conditionally recommended for patients with a prior allergic response to allopurinol who cannot be treated with other oral urate lowering therapy (ULT) agents. The level of evidence backing this recommendation is not that high.
Experts recognized that desensitization protocols are not usually used, with the majority of currently practicing rheumatologists having limited exposure in using the protocol.
Moreover, switching to an alternative oral ULT agent, consistent with other recommendations in this guideline, is conditionally recommended for patients taking febuxostat with a history of cardiovascular disease (CVD).
Among experts, there was much discussion about the data, patient information, and interest to provide recommendations consistent with the Food and Drug Administration (FDA) black box warning for febuxostat. Experts considered data from a randomized control trial and 2 observational studies.
In the FDA- mandated trial of febuxostat versus allopurinol, there was no difference between the 2 drugs when it comes to primary composite CVD end point. Febuxostat, however, was linked with a higher risk of CVD- related death and all- cause mortality compared with allopurinol, but there was no linkage with the other 3 secondary CVD results.
Moreover, the lack of an untreated control group means the CVD risk linked to febuxostat use is unknown. A large observational study was not able to show an increased risk of CVD or all – cause mortality associated with febuxostat use compared with allopurinol.
In another study, it showed lower risk of any major CVD event among febuxostat users than allopurinol initiators.
Experts are willing to accept “some” incremental CVD risk as long as the treatment adequately controlled their gout.
Thus, as for many such decisions with conditional recommendations, providers and patients should engage in shared decision- making when considering febuxostat for patients at high risk for CVD.
Next week we will be discussing the uric acid measurement recommendations in the management of gout.