Comparing Gout Medications: Uloric vs Allopurinol

Summary: When comparing Uloric vs allopurinol it’s not a cut and dried choice. Both drugs attack gout by lowering the blood levels of uric acid. Both drugs also offer advantages and disadvantages and a lot will depend on your personal situation.

Dear Curtis: I have had gout off and on for a few years now. Normally, I can control it by taking colchicine. But, it’s too the point where it’s not working as well. I went into the doctor who measured my Uric Acid level and it’s over 8. My doctor recommends getting it down to 5.0. He basically told me that I have two choices: allopurinol or Uloric. Any advice or feedback is appreciated.

Both allopurinol and Uloric act by lowering the blood levels of Uric Acid – which, in theory, helps relieve gout attacks.

However, both drugs have good, and bad points.

Allopurinol: Proven, Cheap But Dangerous Side Effects

Allopurinol is a drug that has been around for decades and a lot of doctors are very comfortable with it simply because it has become the gold standard for preventing gout attacks.

But, it also comes with a number of issues.

Skin Rash

The most serious, but rare, side effect is a skin rash that can actually be fatal. So, it’s advised that if you start allopurinol and you notice ANY sort of skin rash that you stop immediately.

Gout Attacks

Believe it or not, allopurinol can actually lead to an increase in gout attacks during the first stages of treatment. Frankly, we don’t know why this happens but think it is due to how allopurinol is dosed. It’s recommended that patients start at a dose of 100 mg a day and increase at weekly intervals by no more than 100 mg until the desired uric acid level is reached. The maximum dose for allopurinol is 800 mg per day. But I’ve found this high of a dose to be rare because doctors are nervous about causing side effects.

Other Side Effects

Speaking of side effects, besides the rash above allopurinol can also cause gastrointestinal issues like diarrhea, nausea and increases in liver enzymes. Allopurinol is also known for causing drowsiness. So, if your daily activities depend on you being alert allopurinol may not be the best choice.

Finally, if you have any sort of kidney problems allopurinol is not the best drug to be taking as it can build up in your system and increase the chances of side effects.

Now keep in mind I’ve thrown worst-case scenario at you with allopurinol. I see a LOT of patients on allopurinol. But, before you start it it’s only fair that you know what could happen.

A big part of the reason why you see so much allopurinol prescribed is not just because it’s been the gold standard for decades, but it’s also very inexpensive so that pretty much anyone can afford it.

Uloric: Considered Safer But Much More Expensive and Unproven

Uloric, which acts in a very similar way to allopurinol, has only been on the market since 2009. But, in that time, it’s caused heated debates on whether or not it really offers any advantages compared to allopurinol.

Heart Attack and Stroke Concerns

Early on when Uloric was introduced, it ran into problems because it was being linked to an increase in cardiovascular events like strokes and heart attacks. Uloric still carries a warning for this issue on it’s packaging, but the FDA basically came out and said that it hasn’t been proven beyond a doubt that Uloric was behind the increases.

Side Effect Profile

What’s interesting to me is that when Uloric and allopurinol were compared head-to-head the incidence of side effects was pretty much a wash. For example, allopurinol did cause an increased risk of a skin rash compared to Uloric (1.6% vs 0.5% to 1.6% based on dose). But Uloric lead to a higher risk of nausea (0.8% vs. 1.3%), muscle pain (0.7% vs 1.1%) and liver function abnormalities (4.2% vs 4.6% to 6.6% based on dose). So, while Uloric is the shiny new drug on the shelf it certainly isn’t always better tolerated (1).

Cost

Really, the biggest downside to Uloric is it’s price tag. Of course, prices fluctuate around the country but I think it’s fair to say that you can expect to pay at least $100 a month for Uloric compared to a fraction of that for allopurinol.

My Opinion

Both drugs come with downsides and cause side effects. But both drugs have their place as well. It really depends on your personal situation and your doctor’s opinion.

For example, if you had kidney problems I think Uloric would be the better choice to try. But, if cost is the only concern obviously allopurinol would be the hands-down winner.

Again, the most important point is that you understand the good and bad points of both drugs so that you can make a more informed decision.

Reference:

  1. Uloric [package insert]. Deerfield, IL: Takeda Pharmaceuticals America; February 2009