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PRACTICE: Robin Fox Management of recurrent gout BMJ 2008; 336: 329 [Full text]

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BSR and BHPR Guideline for the Management of Gout

Susie C Earl, Richard Hull   (15 February 2008)

febuxostat holds promise as a xanthine oxidase inhibitor

oscar,m jolobe   (24 February 2008)

BSR and BHPR Guideline for the Management of Gout 15 February 2008
Susie C Earl, Specialist Registrar in Rheumatology Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, Richard Hull Send response to journal: Re: BSR and BHPR Guideline for the Management of Gout	We read with interest the 10-minute consultation on the management of gout. Robin Fox makes some very valid points regarding the management of this common condition and provides a useful, concise summary. We would however like to draw attention to the British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) Guideline for the Management of Gout published in 2007 by Jordan et al. The BSR guidelines state that the plasma urate should be maintained below 300µmol/l to prevent recurrent attacks of gout as opposed to the ≤360µmol/l quoted in the article by Robin Fox. This is an important point since evidence suggests that at plasma urate levels above 300µmol/l recurrent attacks of gout may occur and this is also observed in clinical practice. The BSR guidelines also suggest that uric acid-lowering therapy should be offered to patients following a second attack of gout or if a further attack occurs within a year as opposed to the more than three attacks a year quoted in the article. In addition to those with tophi and urate nephropathy, uric acid lowering therapy should also be offered to patients with renal insufficiency and to those who need to continue treatment with diuretics. As clinicians, gout is one of the most rewarding diseases to manage but many find it confusing and frustrating. This guideline can be accessed via the BSR website (http://www.rheumatology.org.uk/guidelines/guidelines_other/goutguide). Competing interests: None declared
febuxostat holds promise as a xanthine oxidase inhibitor 24 February 2008
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP Send response to journal: Re: febuxostat holds promise as a xanthine oxidase inhibitor	The armamentarium for management of recurrent gout(1) could usefully include febuxostat, a novel nonpurine xanthine oxidase inhibitor which is metabolised mainly in the liver, with the consequence that it does not require dose adjustments for renal impairment(2). This drug has a place where there are concerns about the risk of the allopurinol-related, and potentially fatal hypersensitivity syndrome(3), which is most common in patients with chronic renal disease but can also occur in any patient treated with allopurinol(4). It might also prove useful in patients with documented intolerance of allopurinol or in those in whom it is desirable to avoid the adverse consequences of the interaction betweem allopurinol and drugs such as warfarin, thephylline, azathioprine, and 6- mercaptopurine, respectively(4). References (1) Fox R Management of recurrent gout British Medical Journal 2008:336:329 (2)Mayer MD., Khosravan R., Vernillet I et al Pharmacokinetics and pharmacodynamics of febuxostat, a new non-purine selctive inhibitor of xanthine oxidase, in subjects with renal impairment American Journal of Therapeutics 2005:12:22-34 (3) Moreland LW Febuxostat-Treatment of hyperuricemia and gout? New England Journal of Medicine 2005:353:2505-7 (4)Keith MP., Gilliland WR Updates in the management of gout American Journal of Medicine 2007:120:221-4 Competing interests: None declared