Gout is the oldest recognised form of arthritis, caused by high levels of uric acid in the bloodstream related to high protein diets and foods that are high in purines.

Throughout history it has often been referred to as the ‘Disease of Kings’, a reference to the apparent increased incidence in people living under privileged social conditions. However, it is now observed in a broad spectrum of the population but is more likely in people with obesity, insulin resistance, high blood pressure and blood lipid imbalances.1

It is now a condition on the increase. UK data indicate that between 1997 and 2012 there was a 63.9% increase in prevalence and 29.6% increase in incidence. However, despite the high profile of the condition it remains poorly treated.2

This is highlighted in this issue of RADAR in our review of febuxostat, a newly PBS-listed drug for chronic tophaceous gout. While febuxostat is accepted by the PBAC as a cost-effective and clinically effective agent, the trials underpinning its approval for listing reflect a problem in current gout management.

In the clinical trials considered by the Pharmaceutical Benefits Advisory Committee,3 comparing febuxostat with allopurinol, the dose of allopurinol remained fixed. Guidelines recommend allopurinol dose optimisation by titration to effect, with serum uric acid as the surrogate endpoint target.4

While febuxostat is a useful addition to the clinical management of gout, prescribers are reminded that it is only PBS listed for patients who have a contraindication to, or who are intolerant of, allopurinol and that the response to allopurinol should not be considered to have failed unless adequate dose titration has been implemented.