Gout is the most common inflammatory
arthritis in adults. The prevalence of
gout increases with age.
Urate-lowering treatment (ULT) among older patients is often challenging in that patients frequently suffer insufficient effectiveness or adverse events due to comorbidities, concurrent medications, and altered pharmacokinetics. The large-scale randomized controlled trials (RCTs) directly investigating
gout patients regarding cardiovascular (CV) safety have only recently been introduced; CARES and FAST compared the CV safety of the two
xanthine oxidase inhibitors (XOis),
febuxostat versus
allopurinol, in patients with
gout. Based on the CARES trial that showed CV concerns with
febuxostat, the current international guidelines recommend
allopurinol as first-line ULT in
gout, while preserving other agents as a second-line treatment, despite a higher potency of
febuxostat. XOis would be more suitable than uricosurics to treat older patients with
gout due to the high prevalence of
chronic kidney disease (CKD) in older patients. However,
allopurinol alone might not achieve the target serum
uric acid levels below 6 mg/dL and CKD might confer an increased risk of
allopurinol induced cutaneous adverse reactions in older patients. Furthermore, as well as the later analysis of CARES participants who were lost to follow-up, data from the FAST trial and real-world studies suggest non-inferior CV safety for
febuxostat compared to
allopurinol even in the presence of CV diseases. Thus,
febuxostat use in older patients with renal impairment may be more positively considered. The combination
therapy of a novel uricosuric,
verinurad, plus
febuxostat reduced
albuminuria in hyperuricemic patients with
type 2 diabetes and CKD in a phase 2a trial, and further RCTs are awaited. Finally, the
sodium-
glucose cotransporter-2 inhibitor class of oral
hypoglycemic agents, known to exert beneficial CV and renal effects independent of
glycemic control, have shown a uricosuric effect and could be used as adjunctive
therapy in older patients with cardiorenal comorbidities.