Initiating Urate-Lowering Therapy for Gout

Strong Recommendation for Concurrent Use

The American College of Rheumatology strongly recommends administering concomitant anti-inflammatory prophylaxis therapy, including prednisone, when initiating febuxostat or any urate-lowering therapy, as this combination is considered standard of care to prevent gout flares during the initial months of treatment 1, 2
The American College of Rheumatology recommends that febuxostat and prednisone can and should be given together when initiating urate-lowering therapy for gout 1

Continue prednisone prophylaxis for 3-6 months minimum when starting febuxostat, with extension beyond 6 months if the patient continues to experience flares, according to the American College of Rheumatology 1
Start febuxostat at low dose, 40 mg daily or less, then titrate upward every 2-4 weeks to reach target serum urate <6 mg/dL, as recommended by the American College of Rheumatology 1

Febuxostat has very few known drug interactions, with the most important being azathioprine, according to the British Journal of Dermatology 3

Never combine febuxostat with azathioprine, as this carries a substantially increased risk of life-threatening myelotoxicity, as warned by the British Journal of Dermatology 3

Monitor for corticosteroid side effects, such as mood disorders, dysphoria, elevated blood glucose, immune suppression, and fluid retention, as recommended by the Annals of Internal Medicine 2
If prednisone is contraindicated, colchicine or NSAIDs are equally recommended alternatives for flare prophylaxis, according to the American College of Rheumatology 1

Discontinuing prednisone before 3 months increases flare risk during the critical period when urate crystals are mobilizing, as warned by the American College of Rheumatology 1
The 7.5 mg daily prednisone dose is for flare prevention, while acute gout flares require higher therapeutic doses of corticosteroids, as recommended by the Annals of Internal Medicine 2