Letter to the Editor

In the recent excellent article, “Aggressive Urate Lowering Needed for Gout,” on the therapeutic update of aggressive treatment of gout, there are the following points that need to be looked at:

1. The paragraph on febuxostat said that the 40-mg dose outperformed the 80-mg dose and really impaired patients. I think it should be that the 80-mg dose of febuxostate outperformed the 300-mg dose of allopurinol. The 40-mg dose, I believe, was equal to allopurinol in its efficacy generally.
2. N. Lawrence Edwards, MD, mentions the need to use allopurinol, a much cheaper drug that has been around since the late 1960s to early 1970s. He mentions that this drug is underutilized and I certainly agree with him. In addition, over 50% of patients never get above 300 mg and the need to titrate this up to the proper level. What he does not say is, as far as I know, there are no studies on using allopurinol greater than 300 mg daily in patients who have had renal insufficiency. Even though there are some new case reports of febuxostat causing skin rashes and possibly even a case of Stevens-Johnson syndrome, it is nowhere near as significant a problem as allopurinol in renally impaired patients causing at least 0.25% to develop the very severe allopurinol hypersensitivity syndrome, which has a 25% mortality.

Physicians, experts like myself who have had almost forty years of treating thousands of patients with hyperuricemia and gout, have welcomed febuxostat for patients who have mild to moderate renal insufficiency. In that regard, we have some early studies suggesting that it is relatively safe and no studies telling us whether allopurinol is safe. Although my own bias is that it probably will be and could be used in patients with mild renal insufficiency without much difficulty, just with close observation.

Alan Zalkowitz, MD
New Jersey Associates in Medicine, PA
Fair Lawn, N.J.