Treat to a target urate, not to symptoms. Allopurinol is unrestricted first-line. Febuxostat is the Authority Required (Streamlined) alternative — but only for documented allopurinol hypersensitivity, intolerance or contraindication. Inadequate response to allopurinol alone is not a PBS-funded indication for febuxostat.
1When to start ULT
✓Recurrent flares — Two or more gout flares per year — the commonest trigger to start urate-lowering therapy.
✓Tophi or erosions — Any tophus, or joint damage/erosions seen on imaging.
✓Urate stones / CKD — Urate nephrolithiasis, or gout with CKD stage 3 or worse.
✓Target urate — Aim below 0.36 mmol/L; below 0.30 mmol/L if tophaceous or severe.
2Allopurinol vs febuxostat
| Feature | Allopurinol | Febuxostat |
|---|
| PBS status | Unrestricted (first-line) | Authority required (Streamlined) — allopurinol intolerance/hypersensitivity/contraindication only |
| Starting dose | 100 mg daily (50 mg if CKD); titrate to target | 80 mg once daily; up to 120 mg if target not reached |
| Key risk | Hypersensitivity (SCAR) — screen HLA-B*5801 in at-risk groups | CV signal (CARES) — avoid in major cardiovascular disease |
Verify at PBS — Start low, go slow — cover the first 3–6 months with flare prophylaxis (low-dose colchicine or an NSAID) and don't start ULT mid-flare. Exact titration steps and item codes are not reproduced here — confirm at pbs.gov.au.
Safety
- Don't start ULT mid-flare — wait ~2–4 weeks for the acute attack to settle.
- If already on ULT, continue it through an acute flare — don't stop.
- Treat flares early: NSAID, colchicine or corticosteroid — effectiveness falls the longer the flare runs.
- ULT is lifelong — recheck urate periodically and keep it at target.
Check / exclude
- Screen HLA-B*5801 before allopurinol in Han Chinese, Thai and Korean (CKD) patients — severe cutaneous reaction risk.
- Avoid both allopurinol and febuxostat with azathioprine/6-mercaptopurine — shared xanthine oxidase pathway, potentially life-threatening.
- Febuxostat: avoid in major cardiovascular disease — assess CV risk first.
- Colchicine: reduce dose in renal/hepatic impairment; interacts with statins, clarithromycin, verapamil.
EN-07 v1.0 · Reviewed Jun 2026 · Review Dec 2026
For health-professional use. Eligibility and dosing summarised from public PBS reporting — confirm exact wording at pbs.gov.au. Covers allopurinol and febuxostat for chronic gout — not a complete dose-and-titration matrix.
