Gout with Allopurinol Allergy or Intolerance: When Combination Therapy Fails to Reach the Uric Acid Target
Clinical Scenario
This protocol applies to patients with gout who cannot use allopurinol — due to allergy or intolerance — and who have already been treated with an alternative combination regimen that did not achieve the required serum uric acid target.
In this population, standard first- and second-line urate-lowering options have been exhausted or are contraindicated, and further escalation is needed.
Previous Step — Insufficient Response
The prior regimen of febuxostat combined with a uricosuric did not bring serum uric acid below the target of 6 mg/dL — or below 5 mg/dL in patients with severe gout. This failure to reach the uric acid target is the trigger for escalation to the next step.
Clinical Goals
- Serum uric acid level <6 mg/dL (360 µmol/L)
- Resolution of tophi
Treatment Approach
For patients with severe, debilitating chronic tophaceous gout and poor quality of life — in whom the uric acid target cannot be achieved with any oral urate-lowering therapy at maximum doses, including combinations — an intravenous urate-lowering agent (pegloticase) is indicated as the next step.
The complete dosing schedule, administration requirements, contraindications, and monitoring plan are available in the full structured regimen below.
References
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.
- In patients with crystal-proven, severe debilitating chronic tophaceous gout and poor quality of life, in whom the SUA target cannot be reached with any other available drug at the maximal dosage (including combinations), pegloticase is indicated.
- In this study, the percentage of responders (SUA level <6 mg/dL) was 42%, on average, in patients who received pegloticase, 8 mg, every 2 weeks and 0% in the placebo group.
- Effective ULT reduces the size and number of tophi and facilitates their disappearance, thereby improving the quality of life of patients with gout.
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