This page addresses gout management in patients with allopurinol allergy or intolerance whose initial single-agent urate-lowering therapy has not achieved the required serum uric acid target.
Allopurinol allergy or intolerance places patients in an alternative urate-lowering treatment pathway. When a serum uric acid target cannot be reached with initial monotherapy in this population, a structured next-line approach is indicated.
This protocol applies when treatment with febuxostat or a uricosuric as a single agent has not achieved:
The following protocol defines the next step when these targets remain unmet.
DOI: 10.1136/annrheumdis-2016-209707
Febuxostat or a uricosuric are also indicated if allopurinol cannot be tolerated.
If the SUA target cannot be reached by an appropriate dose of allopurinol, allopurinol should be switched to febuxostat or a uricosuric, or combined with a uricosuric.
The recommendation to combine benzbromarone or probenecid with an XOI is a novel strategy that should help physicians manage severe gout that is not readily controlled by single agents and not eligible for pegloticase.
For patients on ULT, SUA level should be monitored and maintained to <6 mg/dL (360 mmol/L).
A lower SUA target (<5 mg/dL; 300 mmol/L) to facilitate faster dissolution of crystals is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) until total crystal dissolution and resolution of gout.
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