From the Guidelines
Allopurinol should be switched to febuxostat in patients with hyperuricemia when they have moderate to severe kidney impairment (CrCl <60 mL/min) or experience severe hypersensitivity reactions, as febuxostat has been found more effective in patients with CKD than allopurinol given at doses adjusted to creatinine clearance 1.
Key Considerations for Switching
- Patients with renal impairment are at increased risk of severe cutaneous adverse reactions (SCARs) with allopurinol, which can be fatal 1
- Febuxostat can be used in patients with moderate to severe kidney impairment, making it a suitable alternative to allopurinol in these cases
- The dose of febuxostat does not need to be adjusted based on renal function, unlike allopurinol, which requires dose adjustment according to creatinine clearance 1
Clinical Implications
- When switching from allopurinol to febuxostat, there should be no washout period between medications to avoid triggering gout flares
- Prophylaxis with colchicine or an NSAID should be continued for up to 6 months after the switch to prevent gout flares
- Febuxostat works differently than allopurinol as a non-purine selective xanthine oxidase inhibitor, making it effective in patients who cannot tolerate allopurinol 1
Important Safety Considerations
- Febuxostat should be used with caution in patients with cardiovascular disease due to a potentially higher risk of cardiovascular events compared to allopurinol
- Patients should be closely monitored for signs of hypersensitivity reactions or other adverse effects when switching to febuxostat 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Switching from Allopurinol to Febuxostat
- Allopurinol is the traditional treatment for hyperuricemia, but febuxostat is a viable alternative, especially in patients with renal impairment 2, 3.
- Febuxostat does not require dosage adjustment in patients with mild or moderate renal impairment, unlike allopurinol 2.
- Studies have shown that febuxostat is more effective in lowering serum uric acid levels than allopurinol, especially in patients with renal impairment 2, 3.
Indications for Switching
- Patients with chronic kidney disease (CKD) may benefit from switching to febuxostat, as it has been shown to slow the progression of renal disease and reduce serum uric acid levels 3.
- Patients with asymptomatic hyperuricemia may also benefit from febuxostat, as it has been shown to have a renoprotective effect and lower diastolic blood pressure 4.
- Patients who experience hypersensitivity reactions to allopurinol may be switched to febuxostat, which can be used safely in these patients 5.
Considerations
- The decision to switch from allopurinol to febuxostat should be based on individual patient factors, including renal function, serum uric acid levels, and medical history 2, 3, 6.
- Patients with severe renal impairment or hepatic impairment may require closer monitoring and dose adjustment when switching to febuxostat 5.
- Further research is needed to determine the long-term benefits and risks of febuxostat, especially in comparison to high-dose allopurinol (> 300 mg) 5.