Department of Rheumatology, Hôpital Lariboisière, APHP.
Université Paris Diderot.
Curr Opin Rheumatol. 2019 Mar;31(2):152-158. doi: 10.1097/BOR.0000000000000573.
Concerns about the cardiovascular safety of febuxostat lead to reconsideration of the place of febuxostat in the management of gout.
The CARES trial is a randomized controlled trial mandated by the FDA to compare the cardiovascular safety of febuxostat and allopurinol in the management of gout. About 6190 patients with gout and major cardiovascular disease, randomly assigned to allopurinol or febuxostat, were prospectively followed up for a median of 32 months. No difference was noted in the occurrence of the primary end-point event, a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or unstable angina with urgent revascularization, but cardiovascular death was significantly more common in the febuxostat group (4.3%) as compared with the allopurinol group (3.2%) (P = 0.03).
Present guidelines on the management of gout should be revised in view of recent findings. Allopurinol could be recommended as the sole first-line urate-lowering drug (ULD) in patients with no contraindication. In patients contraindicated to allopurinol, uricosurics could be preferred to febuxostat as first-line ULDs in patients with cardiovascular disease/risk factors and no history of uric acid stones.
人们对非布司他心血管安全性的担忧，促使重新考虑其在痛风治疗中的地位。
CARES 试验是由 FDA 授权的一项随机对照试验，旨在比较非布司他和别嘌醇在痛风治疗中的心血管安全性。大约 6190 例患有痛风和主要心血管疾病的患者被随机分配至别嘌醇或非布司他组，前瞻性随访中位数为 32 个月。主要终点事件（心血管死亡、非致死性心肌梗死、非致死性卒中和需要紧急血运重建的不稳定型心绞痛的复合事件）的发生率无差异，但非布司他组心血管死亡（4.3%）明显高于别嘌醇组（3.2%）（P=0.03）。
鉴于最近的发现，应修订当前痛风管理指南。在无禁忌证的患者中，别嘌醇可作为唯一的一线降尿酸药物（ULD）。在有禁忌证的患者中，对于有心血管疾病/危险因素且无尿酸结石病史的患者，可首选促尿酸排泄药而非布司他作为一线 ULD。
