Febuxostat

How it works

It inhibits xanthine oxidase, reducing the conversion of hypoxanthine and xanthine to uric acid and thereby lowering serum urate.

Prescribing in practice

• Use with caution in patients with major cardiovascular disease because of signals of increased cardiovascular events compared with allopurinol; weigh risks in older patients with ischaemic heart disease or prior stroke.
• Gout flares are common when urate-lowering therapy starts, so co-prescribe flare prophylaxis and do not stop febuxostat during an acute attack.
• Serious hypersensitivity reactions can occur; stop immediately and seek advice if a rash develops.

Monitoring

Monitor serum urate to confirm response, and review cardiovascular status and liver function periodically during treatment.

Counselling the patient

• Keep taking it during a gout attack; stopping can make flares worse.
• Flares may increase when starting; preventive cover is usually given for a period.
• Report any skin rash, chest pain or new neurological symptoms promptly.

Evidence & guidelines

The CARES and FAST cardiovascular outcome trials informed regulatory advice on cautious use of febuxostat in patients with established cardiovascular disease.