Long term control of gout
Please see Febuxostat: updated advice for the treatment of patients with a history of major cardiovascular disease - GOV.UK and Recommendations | Gout: diagnosis and management | Guidance | NICE. NG 219 suggests for the long-term management of gout : Offer allopurinol as first-line treatment to people with gout who have major cardiovascular disease (for example, previous myocardial infarction or stroke, or unstable angina).”
NICE guidance (see also drug specific guidance below)
NG219:Gout: diagnosis and management, published June 2022.
This is the drug of choice for prophylaxis. It should not be started during an acute attack but 1-2 weeks after the attack has settled. The initiation of allopurinol may precipitate an acute attack, so an NSAID or low dose colchicine (500mcg 1 - 2 times daily) should be used as a prophylactic and continued for at least 1 month after the hyperuricaemia has been corrected.
This is a non-purine, xanthine oxidase inhibitor licensed for the treatment of chronic hyperuricaemia in adults, in whom urate deposition has already occured (including a history, or presence of, tophus and/or gouty arthritis). Febuxostat has been approved by NICE for use in patients with gout where allopurinol is contraindicated or not tolerated, (but take great care if the patient has a history of hypersensitivity to allopurinol - see warning above).
Crystallisation of urate in the urine can occur with uricosuric drugs below, therefore it is important to ensure adequate urine output in the first few weeks of treatment.
Aspirin and other salicylates antagonise uricosuric drugs, and so are not indicated in gout.