Febuxostat versus Allopurinol : which is better in older patients of Gout with CV Risk

Urate-lowering treatment for gout and may have different effects on cardiovascular risk in patients with gout, according to a study recently published in the journal Circulation.

MaryAnn Zhang and his colleagues conducted a cohort study for the comparative cardiovascular safety of initiating febuxostat versus allopurinol among gout patients aged ≥65 years. The primary outcome was a composite endpoint of hospitalization for myocardial infarction (MI) or stroke. Secondary outcomes were individual endpoints of hospitalization for MI, stroke, coronary revascularization, new and recurrent heart failure (HF), and all-cause mortality.

Propensity score (PS) matching with a ratio of 1:3 was used to control for confounding. Incidence rates (IR) and hazard ratios (HR) for primary and secondary outcomes in the PS-matched cohorts of febuxostat and allopurinol initiators was estimated. The study included 24,936 febuxostat initiators PS-matched to 74,808 allopurinol initiators out of which 52% were male, and 12% with an average age of 76 years, had cardiovascular disease at baseline.

Key findings:

• Incidence rate (IR) per 100 person-years for the primary outcome was 3.43 in febuxostat and 3.36 in allopurinol initiators.


• HR for the primary outcome was 1.01 in the febuxostat compared to allopurinol groups.


• Risk of secondary outcomes including all-cause mortality was similar in both groups, except for a modestly decreased risk of HF exacerbation in febuxostat initiators.


• The HR for all-cause mortality associated with long-term use of febuxostat (>3 years) was 1.25 versus allopurinol. Subgroup and sensitivity analyses consistently showed similar cardiovascular risk in both groups.

The study concluded that among patients with gout, overall there was no difference in the risk of MI, stroke, new-onset HF, coronary revascularization, or all-cause mortality between patients initiating febuxostat compared with allopurinol. Though not statistically significant, the study showed an increased trend towards the risk for all-cause mortality in patients who used febuxostat for over 3 years versus allopurinol for over 3 years. The risk of HF exacerbation was slightly lower in febuxostat initiators.

Gout is a disease in which the defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet. The elevated uric acid in the bloodstream commonly leads to sudden episodes of acute inflammatory joint pain, stiffness, and swelling.

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http://circ.ahajournals.org/content/early/2018/06/12/CIRCULATIONAHA.118.033992