Urate-lowering therapy remains the cornerstone of long-term gout management, with allopurinol and febuxostat being the two most commonly prescribed medications. However, the choice of therapy should be individualized based on the patient’s clinical characteristics, renal and hepatic function, and cardiovascular risk profile to ensure both efficacy and long-term safety.

Febuxostat is a xanthine oxidase inhibitor that reduces uric acid production and is indicated for the treatment of chronic hyperuricemia in patients with established urate crystal deposition.

In 2019, the United Kingdom’s Medicines and Healthcare products Regulatory Agency (MHRA) advised healthcare professionals to avoid the use of febuxostat in patients with a history of major cardiovascular disease, including myocardial infarction, stroke, or unstable angina, unless no other appropriate treatment options are available.

More recently, on January 30, 2025, the French National Agency for Medicines and Health Products Safety (ANSM) updated its recommendations regarding urate-lowering therapies.

According to these recommendations, allopurinol remains the first-line treatment for most patients with gout. Febuxostat should generally be reserved for patients who are unable to tolerate allopurinol or whose serum uric acid levels remain inadequately controlled despite allopurinol therapy.

Experts also recommend initiating allopurinol at a low dose and gradually titrating upward according to treatment response, with the goal of achieving and maintaining a serum uric acid level below 5 mg/dL (300 μmol/L).

For patients with chronic kidney disease, dose adjustment should be guided by the estimated glomerular filtration rate (eGFR):

• eGFR > 60 mL/min/1.73 m²: Allopurinol is preferred, starting at 100 mg daily and titrated according to treatment response.
• eGFR 30–60 mL/min/1.73 m²: Allopurinol should be used cautiously, beginning at a lower dose with gradual adjustments.
• eGFR 15–30 mL/min/1.73 m²: Febuxostat may be considered preferentially because of the increased risk of severe hypersensitivity reactions associated with allopurinol in this patient population.
• In addition, febuxostat should be prescribed with caution in patients with a history of significant cardiovascular disease. For patients receiving febuxostat 80 mg whose serum uric acid levels remain above 6 mg/dL after 2–4 weeks of treatment, escalation to 120 mg may be considered, accompanied by careful monitoring of liver function.

Experts emphasize that gout management extends beyond controlling acute attacks. The primary long-term objective is sustained control of serum uric acid levels to prevent crystal deposition, disease progression, and complications.

Therefore, medication selection, dose adjustment, and ongoing monitoring should be individualized for each patient, particularly those with coexisting cardiovascular disease, hepatic impairment, or renal dysfunction.

At Bach Mai Hospital, febuxostat-containing products currently available include Febuliv 40 mg and Ulfebix 80 mg, while the available allopurinol-containing product is Sadapron 300 mg.

Patients are advised not to change medications or adjust treatment doses without consulting their healthcare provider. Adherence to prescribed therapy and regular follow-up are essential for effective gout control, reducing complications, and improving long-term quality of life.