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Xanthine Oxidase Inhibitor — Urate-lowering Therapy Pregnancy: Avoid — insufficient data. Colchicine or prednisolone for acute gout in pregnancy.

Febuxostat

Brand names: Adenuric

Adult dose

Dose: Gout: 80mg OD initially; increase to 120mg OD after 2–4 weeks if serum urate target not achieved (<360 micromol/L). As per allopurinol: start during quiescent period only; co-prescribe colchicine prophylaxis for ≥6 months.
Route: Oral
Frequency: Once daily (with or without food)
Max: 120mg OD
Alternative to allopurinol — non-purine selective xanthine oxidase inhibitor. Preferred when allopurinol not tolerated or contraindicated. MHRA 2019: febuxostat associated with increased risk of cardiovascular death vs. allopurinol (FAST trial) — restrict to patients where allopurinol is not appropriate; avoid in established CV disease (ischaemic heart disease, heart failure). Start with colchicine prophylaxis.

Paediatric dose

Route: Oral
Frequency: Once daily
Max: Not applicable
Not licensed under 18 years. Seek specialist paediatric rheumatology opinion.

Dose adjustments

Renal

eGFR 15–59: 80mg OD (do not increase to 120mg if eGFR <30). eGFR <15: limited data — use with caution.

Hepatic

Mild-moderate hepatic impairment: no adjustment. Severe: not recommended — limited data.

Clinical pearls

  • MHRA 2019 restriction: febuxostat should only be used when allopurinol is not suitable — the FAST trial showed higher cardiovascular death rates with febuxostat vs. allopurinol in patients with established CV disease. Avoid in IHD, heart failure, stroke history
  • Does not require dose reduction in mild-moderate renal impairment (unlike allopurinol) — advantage in CKD stages 3–4 where allopurinol dose titration is complex
  • Azathioprine interaction identical to allopurinol — always check azathioprine/mercaptopurine use before prescribing
  • Colchicine prophylaxis: mandatory at initiation — gout flares are very common in the first 6 months of urate-lowering therapy as urate crystals mobilise

Contraindications

  • Established cardiovascular disease (IHD, heart failure) — MHRA warning
  • Azathioprine or mercaptopurine use (same interaction as allopurinol — fatal bone marrow suppression)
  • Hypersensitivity to febuxostat

Side effects

  • Gout flare at initiation (as per allopurinol — use colchicine prophylaxis)
  • Liver enzyme elevation
  • Rash (including SJS — less common than allopurinol)
  • Cardiovascular events (FAST trial signal — increased CV mortality)
  • Nausea
  • Diarrhoea

Interactions

  • Azathioprine / mercaptopurine — CONTRAINDICATED (same as allopurinol — bone marrow suppression)
  • Theophylline — febuxostat inhibits xanthine oxidase; theophylline metabolite levels may rise; monitor

Monitoring

  • Serum urate (every 4 weeks during titration; target <360 micromol/L)
  • LFTs (baseline and periodically)
  • Cardiovascular symptoms (chest pain, dyspnoea — given CV mortality signal)
  • Gout flare frequency

Reference: BNFc; BNF 90; NICE NG219 (Gout); MHRA Febuxostat Safety Update 2019; FAST Trial (Lancet 2020). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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