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Xanthine Oxidase Inhibitor — Urate-Lowering Therapy Pregnancy: Avoid in pregnancy

Febuxostat

Brand names: Adenuric

Adult dose

Dose: 80-120 mg once daily
Route: Oral
Frequency: Once daily
Max: 120 mg/day
Second-line to allopurinol. Start 80 mg; increase to 120 mg if serum urate target not achieved after 2-4 weeks

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Seek specialist opinion

Dose adjustments

Renal

No dose adjustment required for eGFR 30-89; use with caution if eGFR under 30

Hepatic

Avoid in severe hepatic impairment

Paediatric weight-based calculator

Seek specialist opinion

Clinical pearls

  • MHRA 2019 safety alert: FAST trial showed febuxostat associated with increased all-cause and cardiovascular mortality compared to allopurinol in patients with established cardiovascular disease — avoid in patients with ischaemic heart disease or heart failure
  • Preferred over allopurinol when allopurinol is contraindicated (severe hypersensitivity) or not tolerated, particularly useful in moderate renal impairment (eGFR 30-59) where allopurinol dosing is restricted
  • Does not require dose reduction in mild-moderate renal impairment — practical advantage over allopurinol in elderly with CKD
  • Same precautions as allopurinol: do not start during acute attack; co-prescribe colchicine prophylaxis for first 6 months
  • Azathioprine interaction is equally dangerous as with allopurinol — check all medications

Contraindications

  • Do not start during acute gout attack
  • Established ischaemic heart disease or heart failure (MHRA 2019 warning)

Side effects

  • Gout flare on initiation
  • Nausea and diarrhoea
  • Headache
  • Liver enzyme elevation
  • Cardiovascular events (MHRA 2019 safety concern)

Interactions

  • Azathioprine / mercaptopurine (same dangerous interaction as allopurinol — avoid)
  • Theophylline (increases theophylline levels)

Monitoring

  • Serum urate (target under 360 micromol/L)
  • LFTs
  • Cardiovascular risk assessment
  • Signs of gout flare

Reference: BNFc; BNF 90; NICE CG177 (Gout); MHRA Drug Safety Update 2019 (febuxostat cardiovascular risk); FAST Trial. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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