From the Guidelines
Allopurinol (Zyloprim) is the preferred treatment for a patient with hyperuricemia and heart failure in atrial fibrillation (AF).
Key Considerations
- Starting dose: Allopurinol should be started at a low dose (100 mg/day) and increased by 100 mg increments every 2–4 weeks if required, to reach the uricaemic target 1.
- Dose adjustment in renal impairment: The allopurinol maximum dosage should be adjusted to creatinine clearance in patients with renal impairment 1.
- Alternative treatment: Febuxostat (Uloric) is an alternative treatment if allopurinol cannot be tolerated or if the SUA target cannot be reached with allopurinol 1.
- Monitoring: Serum uric acid (SUA) level should be monitored and maintained to <6 mg/dL (360 mmol/L) lifelong 1.
Rationale
The European League Against Rheumatism (EULAR) recommends allopurinol as the first-line urate-lowering therapy (ULT) for patients with gout, including those with hyperuricemia and heart failure in atrial fibrillation (AF) 1. Febuxostat is recommended as an alternative treatment if allopurinol is not tolerated or if the SUA target cannot be reached with allopurinol 1. The dose of allopurinol should be adjusted according to creatinine clearance in patients with renal impairment to minimize the risk of severe cutaneous adverse reactions (SCARs) 1.
Important Considerations
- Combination therapy: Combination of allopurinol with a uricosuric, such as probenecid, may be considered in patients with severe gout who do not respond to single-agent therapy 1.
- Pegloticase: Pegloticase may be considered in patients with severe, refractory gout who have not responded to other ULT options 1.
From the Research
Treatment Options for Hyperuricemia and Heart Failure in Atrial Fibrillation
The treatment of hyperuricemia in patients with heart failure and atrial fibrillation (AF) is crucial, and two commonly used medications are Allopurinol (Zyloprim) and Febuxostat (Uloric). The preferred treatment option between these two medications can be determined by examining the available evidence.
Comparison of Allopurinol and Febuxostat
- A network meta-analysis study 2 found that there was no significant difference between febuxostat, allopurinol, and placebo regarding cardiovascular outcomes in hyperuricemic patients.
- A post hoc subgroup analysis 3 found that febuxostat reduced the risk of adverse clinical outcomes in patients with asymptomatic hyperuricemia and cardiovascular disease, including those with heart failure.
- A propensity-matched analysis 4 found that febuxostat was associated with a higher risk of atrial fibrillation compared to allopurinol in older adults.
- A multicenter randomized controlled trial 5 found that febuxostat was potentially more effective than allopurinol for treating patients with chronic heart failure and hyperuricemia.
- A propensity score matched analysis 6 found that treatment with allopurinol did not improve the long-term prognosis of heart failure patients with hyperuricemia.
Considerations for Treatment
- The choice between allopurinol and febuxostat should be based on individual patient characteristics and medical history.
- Febuxostat may be a better option for patients with heart failure and hyperuricemia, as it has been shown to reduce the risk of adverse clinical outcomes in this population 3, 5.
- However, febuxostat may also increase the risk of atrial fibrillation in older adults 4, which should be taken into consideration when making treatment decisions.
- Allopurinol may not improve the long-term prognosis of heart failure patients with hyperuricemia 6, but it may still be a viable treatment option for some patients.