Do People With Tophaceous Gout Require More Allopurinol for Good Clinical Outcomes? Analysis of 2 Randomized...

Current prescribing recommendations support higher doses of allopurinol in tophaceous gout to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels. The aim of this study was to determine whether outcomes differ between individuals with and without tophi during 1 year of allopurinol prescribed according to a serum urate (SU) target.

Individual-level participant data from 2 randomized trials of gout (n = 383) were analyzed. Both trials used a treat-to-target strategy with allopurinol and an SU target of < 0.36 mmol/L. The primary outcome was the percentage of participants at target-level SU at month 12 among those with and without tophi. Secondary outcomes included the absence of gout flares. The percentages of participants with target- level SU and the absence of gout flares were compared between those with and without baseline tophi using the Cochran-Mantel-Haenszel test, controlling for study.

Most participants were male, were of European ethnicity, and had longstanding gout. Tophi were present in 33% of participants. There was no statistically significant difference in the percentage of participants with target-level SU at 12 months between those with and without tophi (70.3% vs 73.6%; P = 0.76) nor in the percentage of participants without gout flares during the month before month 12 between those with and without tophi (71.4% vs 79.7%; P = 0.27).

Despite the higher monosodium urate crystal burden in those with tophi, key gout outcomes, including urate-lowering efficacy and absence of gout flares, did not differ from those without tophi when allopurinol was prescribed.