Gout and Cytotoxic-Induced Hyperuricaemia

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

In December 2014, the MHRA issued new contraindications and warnings for DICLOFENAC following a review of the cardiovascular risk which states is similar to that of the selective COX-2 inhibitors. Please refer to the MHRA Drug Safety Update: Diclofenac: New contraindications and warnings.

Choice of agent depends on patient preference, renal function and co-morbidities.

PPIs should be co-prescribed with NSAIDs in those at risk of GI complications.

ASPIRIN is not indicated in gout.

Please refer to the NHSL Guidelines: Management of Gout for Healthcare Professionals.

Acute Attacks of Gout

Preferred list (P)

NAPROXEN

COLCHICINE

Total list (T)

DICLOFENAC

ETORICOXIB

  • ETORICOXIB for acute gout should only be used for a maximum of 8 days.

Long Term Control of Gout

Preferred list (P)

ALLOPURINOL

Total list (T)

FEBUXOSTAT

  • MHRA: Drug Safety Update May 2023:
    'Caution is required if prescribing febuxostat in patients with pre-existing major cardiovascular disease, particularly in those with evidence of high urate crystal and tophi burden or those initiating urate-lowering therapy.'

Prescribing Notes:

  • Urate-lowering therapy (ULT) should be discussed and offered to all people with a diagnosis of gout.
  • Start ULT after the acute attack has resolved. ALLOPURINOL is the recommended first line agent. FEBUXOSTAT may be considered if ALLOPURINOL is not tolerated, if renal function prevents sufficient dose escalation, or target uric acid not reached despite dose escalation.
  • In circumstances where attacks are so frequent that this is not possible, the initiation of ALLOPURINOL can be considered before inflammation has completely settled.
  • Start at a low dose and titrate upwards (where tolerated) every four weeks until the serum uric acid (SUA) level is below 300 micromol/L.
  • For people with renal impairment starting dose and titration guidance may differ.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.