UK’s National Institute of Health and Clinical Excellence doesn’t think so. In December it issued guidance that the benefits febuxostat (sold in the US under the brand name Uloric®) have not been clearly demonstrated.
The argument is that the pharmaceutical companies tested febuxostat against a fixed dose of 300mg of allopurinol per day. Even though this is the way most doctors prescribe allopurinol, it is not the best way to use it according the expert “best practices” guidelines. The appropriate way is to adjust the dose of allopurinol until uric acid levels are lowered to below 6mg/dL (333µm/L). Allopurinol can safely be prescribed up to 900mg/day.
Because the pharmaceutical companies did not show that febuxostat was more effective than allopurinol when allopurinol is used this way, and because of the cost and other risks, they concluded that for most people it best to just stick with allopurinol.
“However, it concluded that the benefits of febuxostat compared with allopurinol (using a fully titrated dosing schedule) in improving clinical outcomes, such as gout flare control, reduction in tophi size and number, and avoidance of joint and organ damage as a result of urate deposition in the longer term, had not been clearly demonstrated.”
Of course the pharmaceutical companies appealed this decision. After reviewing the evidence their appeal eventually failed.
The National Institute of Health and Clinical Excellence stated that febuxostat should only be used in people that are intolerant of allopurinol (have strong or dangerous side effects), or for whom allopurinol is contradicted (people with health conditions that are known to be aggravated by allopurinol). Except for these cases, they conclude, doctors should stick with allopurinol. Again, it’s important for doctors to regularly test blood uric acid levels and adjust the dose to keep levels to below 6mg/dL (333µm/L).
The National Institute of Health and Clinical Excellence also noted that people with ischaemic heart disease or congestive heart failure should not take febuxostat in any case as the risks of complications is too great.
It’s great that the pharmaceutical companies are paying attention to gout again and that they are developing new drugs. But we need to be careful not throw out a perfectly good solution that has the benefit of over forty years of history behind it. Allopurinol has been around for a long time. It’s effects and reactions are well understood. For this reason, its better to stick with a known solution then one that has only had a few clinical trials behind it.
However, if you are one of those that cannot take allopurinol or probenecid, then febuxostat is the medication you have been waiting for.
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