From the Guidelines
No, febuxostat should not be started during an acute gout attack. It is recommended to wait until the acute gout flare has resolved, typically 2-4 weeks after the attack subsides, before initiating febuxostat 1. Starting urate-lowering therapy like febuxostat during an acute attack can potentially worsen or prolong the flare. Instead, the acute gout attack should be managed with anti-inflammatory medications such as:
- Colchicine (0.6 mg once or twice daily)
- NSAIDs like naproxen (500 mg twice daily)
- Corticosteroids like prednisone (starting at 30-40 mg daily with a taper) Once the acute attack has resolved, febuxostat can be initiated at 40 mg daily, potentially increasing to 80 mg daily if needed to reach target uric acid levels below 6 mg/dL. When starting febuxostat, prophylactic therapy with low-dose colchicine (0.6 mg daily) or an NSAID should be used for 3-6 months to prevent flares that commonly occur when urate levels are changing. This approach is recommended because rapid changes in serum urate levels, whether increasing or decreasing, can trigger gout flares by causing urate crystal mobilization from tissue deposits. High-quality evidence showed that prophylactic therapy with low-dose colchicine or low-dose NSAIDs reduces the risk for acute gout attacks in patients initiating urate-lowering therapy 1. Moderate-quality evidence also showed that continuing prophylactic treatment for more than 8 weeks was more effective than shorter durations to help prevent gout flares in patients initiating urate-lowering therapy. The benefits of long-term use of urate-lowering therapy in patients with a single or infrequent gout attacks have not been studied, and urate-lowering therapy is not necessary in cases where the patient would have no or infrequent recurrences. In cases of recurrent gout or problematic gout, shared decision making with the patient is warranted to review possible harms and benefits of urate-lowering therapy. Febuxostat (40 mg/d) and allopurinol (300 mg/d) are equally effective at decreasing serum urate levels, but are associated with adverse effects, including rash with allopurinol and abdominal pain, diarrhea, and musculoskeletal pain with febuxostat. Data on the most appropriate duration of urate-lowering therapy are insufficient, but moderate- to high-quality evidence suggests that urate-lowering therapy reduces the risk for acute gout attacks after 1 year, but not within the first 6 months of treatment. High-value care involves selecting from among corticosteroids, NSAIDs, or colchicine as first-line therapy on the basis of costs when treating patients with acute gout who do not have contraindications. The American College of Physicians recommends that clinicians choose corticosteroids, NSAIDs, or colchicine to treat patients with acute gout, and that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. Evidence is insufficient to determine whether treatment of patients with gout should vary according to patient demographic characteristics, comorbidities, gout severity, clinical presentation, or laboratory values. The effect of dietary treatments on gout is uncertain, and there is little evidence about the long-term benefits or harms of febuxostat. Clinicians should select from among corticosteroids, NSAIDs, or colchicine as first-line therapy on the basis of costs when treating patients with acute gout who do not have contraindications. High-quality evidence shows that prophylactic therapy with low-dose colchicine or low-dose NSAIDs effectively reduces acute gout flares in patients initiating urate-lowering therapy, and moderate-quality evidence supports continuing prophylactic therapy for more than 8 weeks. Evidence was insufficient about whether urate-lowering therapy can be safely discontinued after 5 years. Target thresholds for serum urate levels rely on the chemistry of urate, which is soluble up to a concentration of about 404 µmol/L (6.8 mg/dL), above which precipitation may occur. However, this threshold is not absolute because patients with higher serum urate levels may still be asymptomatic, and some may have acute flares below this threshold. Although there is an association between lower urate levels and fewer gout flares, the extent to which use of urate-lowering therapy to achieve various targets can reduce gout flares is uncertain. The American College of Physicians guideline on management of acute and recurrent gout provides a summary of the recommendations and clinical considerations. In summary, febuxostat should not be started during an acute gout attack, and the acute gout attack should be managed with anti-inflammatory medications, with febuxostat initiated after the acute attack has resolved, and prophylactic therapy used to prevent flares.
From the Research
Treatment of Acute Gout
- The treatment of acute gout typically involves nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids 2, 3, 4, 5.
- It is generally recommended to initiate treatment as soon as possible to achieve the best results 2, 4.
- Febuxostat is a urate-lowering therapy (ULT) agent, which is typically used for the long-term management of gout to prevent future attacks, rather than for the treatment of acute gout attacks 2, 3, 4, 6.
Initiation of Febuxostat in Acute Gout
- There is no clear evidence to support the initiation of febuxostat during an acute gout attack 2, 3, 4, 5, 6.
- Long-term treatment with febuxostat should be initiated only after resolution of the acute attack 5.
- The primary goal of febuxostat is to lower serum uric acid levels to prevent future gout attacks, rather than to treat the acute inflammation associated with a gout attack 2, 3, 4, 6.