Cost-effectiveness of allopurinol and febuxostat for the management of gout

Ann Intern Med. 2014 Nov 4;161(9):617-26. doi: 10.7326/M14-0227.


Background: Gout is the most common inflammatory arthritis in the United States.

Objective: To evaluate the cost-effectiveness of urate-lowering treatment strategies for the management of gout.

Design: Markov model.

Data sources: Published literature and expert opinion.

Target population: Patients for whom allopurinol or febuxostat is a suitable initial urate-lowering treatment.

Time horizon: Lifetime.

Perspective: Health care payer.

Intervention: 5 urate-lowering treatment strategies were evaluated: no treatment; allopurinol- or febuxostat-only therapy; allopurinol-febuxostat sequential therapy; and febuxostat-allopurinol sequential therapy. Two dosing scenarios were investigated: fixed dose (80 mg of febuxostat daily, 0.80 success rate; 300 mg of allopurinol daily, 0.39 success rate) and dose escalation (≤120 mg of febuxostat daily, 0.82 success rate; ≤800 mg of allopurinol daily, 0.78 success rate).

Outcome measures: Discounted costs, discounted quality-adjusted life-years, and incremental cost-effectiveness ratios.

Results of base-case analysis: In both dosing scenarios, allopurinol-only therapy was cost-saving. Dose-escalation allopurinol-febuxostat sequential therapy was more costly but more effective than dose-escalation allopurinol therapy, with an incremental cost-effectiveness ratio of $39 400 per quality-adjusted life-year.

Results of sensitivity analysis: The relative rankings of treatments did not change. Our results were relatively sensitive to several potential variations of model assumptions; however, the cost-effectiveness ratios of dose escalation with allopurinol-febuxostat sequential therapy remained lower than the willingness-to-pay threshold of $109 000 per quality-adjusted life-year.

Limitation: Long-term outcome data for patients with gout, including medication adherence, are limited.

Conclusion: Allopurinol single therapy is cost-saving compared with no treatment. Dose-escalation allopurinol-febuxostat sequential therapy is cost-effective compared with accepted willingness-to-pay thresholds.

Primary funding source: Agency for Healthcare Research and Quality.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Allopurinol / administration & dosage
  • Allopurinol / economics*
  • Cost Savings
  • Cost-Benefit Analysis
  • Drug Therapy, Combination / economics
  • Febuxostat
  • Gout / drug therapy*
  • Gout / economics
  • Gout Suppressants / administration & dosage
  • Gout Suppressants / economics*
  • Humans
  • Markov Chains
  • Models, Theoretical
  • Quality-Adjusted Life Years*
  • Thiazoles / administration & dosage
  • Thiazoles / economics*


  • Gout Suppressants
  • Thiazoles
  • Febuxostat
  • Allopurinol