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Gout - Management
Can urate-lowering treatment be stopped in chronic gout?
- Once allopurinol or febuxostat is started, treatment is usually lifelong, especially in people at higher risk:
- Who have renal impairment, gouty tophi, uric acid stones, or those taking long-term diuretics.
- Who have recurrent attacks of gout when trying to stop urate-lowering treatment.
- Consider stopping allopurinol or febuxostat in people who have had a normal serum uric acid level for many years with no acute attacks of gout.
Clarification / Additional information
- If considering discontinuing urate-lowering medication, explain that there is no certainty that a further episode of gout will not recur.
- Make sure they have a supply of home medication to use in an acute attack, but advise them not to start allopurinol or febuxostat immediately if an acute attack develops, and to seek medical advice.
- Stress the importance of a healthy lifestyle and avoidance of trigger factors.
- Provide early and close follow up as needed.
- It is likely that gout attacks will not recur until urate load has become excessive again, so after a long period with a low serum uric acid level, it may be several years till they need to restart.
- Allopurinol or febuxostat may be stopped if a person is unable to tolerate adverse effects.
Basis for recommendation
These recommendations are based on published expert opinion, pragmatic advice and a guideline produced by expert representatives of the British Society for Rheumatology (BSR). The evidence supporting the BSR recommendations is based on a systematic review of literature [Jordan et al, 2007]. The evidence in this area is limited and comes from small observational studies.
- The evidence from one study shows that people with milder gout may be able to stop treatment without any attacks of gout for over 3 years.
- Another observational study (n = 109) suggested that the lower the serum uric acid level prior to stopping urate-lowering therapy, the longer the person will remain free of gout [Perez-Ruiz et al, 2006].
- Discontinuing allopurinol or febuxostat is not common practice but a trial free period may be a pragmatic approach in an elderly person who has remained symptom-free from gout for years, but who takes multiple medications for comorbidities.
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