Febuxostat CV Safety Discussion Post-MI — ESENeph MCQ

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ModerateChronic Kidney DiseaseFebuxostat CV Safety Discussion Post-MIESENeph

A 67-year-old man with CKD G4 and recurrent gout is started on febuxostat after failing to tolerate allopurinol (developed DRESS syndrome). His eGFR is 18 mL/min/1.73m2. He has a history of ischaemic heart disease with a previous MI. What safety concern must be discussed before starting febuxostat?

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Correct answer: D — Potential increased cardiovascular mortality compared to allopurinol

The CARES trial (2018) raised concerns about increased cardiovascular mortality (not events) with febuxostat versus allopurinol in patients with pre-existing cardiovascular disease. Although the FAST trial (2020) subsequently showed non-inferiority of febuxostat for cardiovascular outcomes, the FDA black box warning remains. In this patient with previous MI, the cardiovascular signal must be discussed as part of informed consent. Febuxostat remains appropriate when allopurinol is contraindicated (DRESS/SJS history — rechallenge is absolutely contraindicated) but requires cardiovascular risk-benefit discussion. Febuxostat requires less dose adjustment in CKD compared to allopurinol.

Reference: White et al 2018 – CARES Trial; MacDonald et al 2020 – FAST Trial; MHRA 2019 – Febuxostat Drug Safety Update