Gout Treatments

Given that 90% of Gout sufferers are under-excretors rather than over-producers of uric acid, the logical first-line drug should be a uricosuric agent (UUA: Probenecid, Benzbromarone, Lesinurad) rather than a xanthine oxidase inhibitor (XOI: Allopurinol, Febuxostat).

Benzbromarone works very well, easily halving serum uric acid level, and works fairly in moderately impaired renal clearance, but is not in guidelines and unavailable in many countries due to 2 major concerns:
1) hepatotoxicity — this is uncommon, and can be mitigated by close monitoring of liver function tests;
2) nephrotoxicity & kidney stones — this is due to its powerful inhibition of urate re-uptake at the kidneys, and can be mitigated by disciplined hydration.
As such, the guidelines call for a UUA to be only an add-on to an XOI should treatment target fail to be reached, in an attempt to limit the amount of uric acid cascading through the renal system and potentially harming it.

Allopurinol is the cheap and commonplace drug, but has 2 major hurdles:
1) risk of Severe Cutaneous Adverse Reactions (SCAR) including often fatal Stevens-Johnson Syndrome and hepatotoxicity — especially at higher doses, in those with renal impairment, and in carriers of the gene HLA-B5801 (15% of Han Chinese are carriers, it confers a 80-fold risk, but only 2% of carriers develop SCAR on Allopurinol);
2) unwarranted fear of the above limits adequate dosing to achieve treatment target.
The alternative would be the very costly Febuxostat, which is very effective and comes with far lower (but not nil) risk for SCAR.

The true test of the pudding is what your doctor is eating. I’m on Benzbromarone with Colchicine prophylaxis. I hydrate well. My serum uric acid is on target, in fact, < 4mg%. Regular liver and renal function tests are normal. BP has even come down. And I continue to enjoy my food and beverages unrestrained, just eliminating sugary soft drinks. I’ve no further gout attacks beyond my first.