From the Guidelines
Allopurinol should be switched to febuxostat in patients with hyperuricemia when they have renal impairment, as febuxostat has been found to be more effective in patients with chronic kidney disease (CKD) than allopurinol given at doses adjusted to creatinine clearance 1.
Key Considerations for Switching
- Renal impairment is a key consideration for switching from allopurinol to febuxostat, as allopurinol can increase the risk of severe cutaneous adverse reactions (SCARs) in patients with decreased renal function 1.
- The dose of allopurinol should be adjusted according to creatinine clearance to minimize the risk of SCARs, but febuxostat can be used as an alternative in patients with CKD 1.
- Febuxostat is a selective inhibitor of xanthine oxidase, which may provide a better therapeutic option for patients who do not respond to allopurinol or have intolerance to it.
Clinical Implications
- Patients with hyperuricemia and renal impairment should be considered for switching from allopurinol to febuxostat to minimize the risk of SCARs and optimize uric acid control 1.
- The switch from allopurinol to febuxostat should be done under close monitoring, with regular assessment of renal function, uric acid levels, and potential adverse reactions.
- Prophylaxis with colchicine or an NSAID may be used to prevent gout flares during the transition from allopurinol to febuxostat.
From the Research
Indications for Switching to Febuxostat
- Patients with hyperuricemia and renal impairment may benefit from switching to febuxostat, as it does not require dosage adjustment in patients with mild or moderate renal impairment 2.
- Febuxostat has been shown to be more effective in lowering serum uric acid levels in patients with hyperuricemia and gout than allopurinol, particularly in those with renal impairment 2, 3.
- Patients with chronic kidney disease (CKD) may also benefit from switching to febuxostat, as it has been shown to slow the progression of renal disease and reduce serum uric acid levels 3.
Safety Considerations
- Febuxostat has been associated with an increased risk of cardiovascular events and mortality compared to allopurinol 4.
- However, febuxostat has also been shown to be generally well-tolerated, with frequently reported adverse events including liver function abnormalities, diarrhea, and rash 2.
- Patients with severe disease and persistent hyperuricemia may require careful evaluation of the benefits and risks of switching to febuxostat 5.
Specific Patient Populations
- Renal transplant recipients may benefit from switching to febuxostat, as it has been shown to reduce serum uric acid levels and result in minor short-term improvement of renal function 6.
- Patients with gout and cardiovascular disease may need to be carefully evaluated before switching to febuxostat, due to the potential increased risk of cardiovascular events 4.