Table 4. Treatment options for chronic gout.
| Substance/group | Proposed therapy | Adverse drug effects | Major contraindications | Recommendation grade | Comments |
| Xanthine oxidase inhibitor: allopurinol | Initially 50 to 100 mg/day; increase to max. 800 mg/day | Diarrhea, nausea, vomiting, increased liver enzymes, skin reactions (2%), hypersensitivity syndrome (0.1%) (e17) | Known hypersensitivity to allopurinol | (A) Cochrane review: target serum uric acid levels achieved more frequently with allopurinol than with placebo (33) | Adjust dose in cases of known renal failure (etable) Monitor liver and kidney enzyme levels |
| Xanthine oxidase inhibitor: febuxostat | Initially 80 mg/day, increase to 120 mg/day if necessary | Liver dysfunction, diarrhea, nausea, headache, skin rash | Ischemic heart disease <12 months or decompensated heart failure (32, 34, e19) | (A) Cochrane review: lowers uric acid levels more effectively than allopurinol (34) | If allopurinol not toler‧ated, in cases of renal failure, or if target uric acid level not achieved despite increased allopurinol dose (A) |
| Uricosuric agent: probenecid | Probenecid can be combined with allopurinol if allopurinol alone is insufficiently effective (5) | Irritation of gastrointestinal tract, skin reactions, anorexia | Urolithiasis, advanced renal failure (creatinine clearance <50 ml/min), or increased uric acid production (e.g. during chemotherapy) (5, 14) | (B) There are no placebo-controlled trials of uricosuric agents. RCT (35): probenecid less effective than allopurinol | Take with sufficient fluids to prevent kidney stone formation |
| Selective inhibitor of URAT1 transporter: lesinurad | Authorized in combination with xanthine oxidase inhibitor for treatment-refractory cases since February 2016 (36) | Headache, influenza-like symptoms increased creatinine levels, gastroesophageal reflux | Severe renal failure, tumor lysis syndrome, Lesch–Nyhan syndrome | (B) RCT: lowers uric acid levels more effectively in combination with allopurinol (37) | Further studies required on cardiovascular safety according to the European Medicines Agency (EMA) (e20). Therefore not currently recommended by these authors for patients with cardiovascular events <12 months (c). |
| Uricosuric agent: benzbromarone | Not recommended by these authors due to liver toxicity (38) (C) | ||||
| Uricase: pegloticase | Taken off the market in July 2016 (e21) | Uric acid levels reduced due to breakdown of uric acid into allantoin, which is eliminated in the urine. Adverse drug effects: infusion issues, anaphylaxis, antibody formation. | |||
RCT: Randomized controlled trial