From the Guidelines
For patients with gout who have an allergy to allopurinol, febuxostat (Uloric) is the primary alternative urate-lowering therapy, with a typical starting dose of 40 mg once daily, which can be increased to 80 mg daily if needed to reach target uric acid levels below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Key Considerations
- The choice of febuxostat over other alternatives is based on its efficacy and safety profile, as well as the recommendations from the most recent guidelines 1.
- Other options, such as probenecid, can be considered, but their use may be limited by factors such as renal function and potential side effects 1.
- For acute gout flares in patients allergic to allopurinol, colchicine, NSAIDs, or corticosteroids can be used, with the goal of reducing pain and inflammation while minimizing the risk of adverse effects 1.
Management Strategies
- When starting any urate-lowering therapy, prophylaxis with low-dose colchicine (0.6 mg daily) or an NSAID for 3-6 months is recommended to prevent flares that commonly occur when uric acid levels are changing 1.
- Patients should be educated on the importance of staying well-hydrated, avoiding alcohol and high-purine foods, and maintaining a healthy weight to reduce the risk of gout flares and improve overall health outcomes 1.
- Regular monitoring of serum urate levels and adjustment of therapy as needed is crucial to achieve and maintain target uric acid levels and prevent gout flares 1.
From the Research
Gout Treatment Alternatives for Allopurinol Allergy
- For patients allergic to allopurinol, several alternative treatments are available, including febuxostat, probenecid, benzbromarone, and pegloticase 2, 3, 4, 5.
- Febuxostat is another efficacious urate lowering therapy, but it has received a U.S. FDA black box warning for cardiovascular safety 3.
- Probenecid is a uricosuric agent that may be helpful in patients with normal or diminished urate excretion 4.
- Benzbromarone can be prescribed via a time-limited authorization procedure and is indicated for patients with renal failure precluding the use of effective allopurinol dosages 4.
- Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 3.
Desensitization Strategies
- Desensitization to allopurinol can be attempted in patients with mild cutaneous hypersensitivity reactions, but it is difficult to perform and rarely used 2, 4.
- Various strategies of slow desensitization have been elaborated to reintroduce allopurinol in a part of these patients, mainly patients affected by mild skin reactions as fixed drug eruption or exanthema 2.
New Therapeutic Alternative Molecules
- Novel uricosurics, such as verinurad and arhalofenate, are a class for continued drug development and have future promise 3.
- Rasburicase, an Aspergillus urate oxidase produced by genetic engineering, is indicated to prevent acute hyperuricemia induced by chemotherapy for hematological malignancies, but its use is limited by the absence of a marketing authorization and the need for parenteral administration 4.