Gout drugs
also: allopurinol · febuxostat · colchicine · urate-lowering
Overview
Acute gout vs urate-lowering — and the critical TIMING relationship between them (when to start allopurinol, and how to cover it).
Mechanism
Acute attack: NSAIDs or colchicine (inhibits microtubule formation → ↓neutrophil migration) or corticosteroid → settle inflammation. Urate-lowering: allopurinol and febuxostat inhibit xanthine oxidase → ↓uric acid production (prevent future attacks; do not treat the acute attack).
Indications
- Acute gout attack (NSAID/colchicine/steroid)
- Long-term urate lowering (allopurinol/febuxostat)
- Pseudogout (acute: NSAID/colchicine/steroid)
The agents
Colchicine if NSAID contraindicated; diarrhoea is dose-limiting.
titrate to urate <300
First-line urate-lowering; start ~2–4 weeks AFTER an acute attack settles, WITH colchicine/NSAID cover (starting/stopping precipitates attacks). AZATHIOPRINE interaction (toxicity).
Alternative if allopurinol not tolerated; cardiovascular caution.
Adverse effects
Cover with colchicine/NSAID for the first ~6 months.
Cautions & contraindications
Worsens/prolongs it — wait until settled, then start with cover (if already on it during an attack, continue).
Xanthine oxidase inhibition → thiopurine toxicity (cross-ref).
Interactions
- Azathioprine/mercaptopurine (toxicity); thiazides/loops raise urate (cross-ref)
Monitoring & kinetics
Serum urate (target <300 µmol/L); renal function (colchicine dosing)
Oral. The acute-vs-prophylaxis distinction + timing is the high-yield teaching.
Source: NICE NG219 — Gout · BNF — Gout