Team: Comparing ULT, aka the “Goutbusters”

Base Article: O’Dell JR, Brophy MT, Pillinger MH, et al. Comparative Effectiveness of Allopurinol and Febuxostat in Gout Management [published correction appears in NEJM Evid. 2022 Jul;1(7):EVIDx2200150] [published correction appears in NEJM Evid. 2022 Aug;1(8):EVIDx2200180]. NEJM Evid. 2022;1(3):10.1056/evidoa2100028. doi:10.1056/evidoa2100028

Authors: University of Michigan Fellowship Program

1. Annie Carlton, MD, PhD, first-year rheumatology fellow, University of Michigan
2. Lauren He, MD, first-year rheumatology fellow, University of Michigan
3. Rocio Bautista Sanchez MD, first-year rheumatology fellow, University of Michigan
4. Nia Lucas BS, MPH, medical student, University of Michigan
5. Yasmin Khader, MD, MPH, first-year rheumatology fellow, University of Michigan
6. Stephanie Tancer, MD, second-year rheumatology fellow, University of Michigan
7. Basmah Al Dulaijan MBBS, second-year rheumatology fellow, University of Michigan
8. Maedeh Veyseh MD, second-year rheumatology fellow, University of Michigan
9. Puja Khanna, MD, MPH, Clinical Associate Professor, University of Michigan

Team Overview

Gout: we see it daily, yet that red, angry toe can spook even the most experienced rheumatologist. We struggle with the complexities of lowering urate, particularly in the setting of comorbidities, and ask ourselves the following almost daily: how should we bust that gout in the absence of head-to-head urate lowering therapy (ULT) trials? Our paper focused on the two most common oral medications: allopurinol and febuxostat. This was a multicenter, randomized, double-blind trial that compared allopurinol and febuxostat head-to-head. The trial specifically looked at a) efficacy – how many people have flares after starting ULT, and b) safety – how important is the discussion on cardiovascular (CV) risk when we start febuxostat? This trial was novel as it studied patients across the spectrum of disease, from middle-aged men without comorbidities to elderly patients with CKD stage III, metabolic syndrome, and CVD. After titration of assigned medication in 749 patients, allopurinol was non-inferior to febuxostat in prevention of acute gout flares, including in patients with CKD. While the primary endpoint was non-inferiority, it is notable and reassuring that the flare rates were very similar in each group. Perhaps we want to revisit that Black Box warning regarding CVD events in febuxostat, with only 6.8% CV events in this group vs 8.1% in allopurinol. Ultimately this trial supports both allopurinol and febuxostat as bonafide Goutbusters — and we guarantee this is a trial you will think about frequently in daily practice!

Want to learn more?

See the Q&A on theMednet.org about the following question: Are there any patients with gout in whom you would choose febuxostat first line over allopurinol for urate lowering therapy?

Next report: NORD-STAR

Back to the full list of scouting reports.