What is the management for a patient with a gout flare who is already taking allopurinol (xanthine oxidase inhibitor)?

From the Guidelines

For a patient experiencing a gout flare while already taking allopurinol, continue the allopurinol without interruption while adding anti-inflammatory treatment for the acute flare. The management of gout flares in patients already on allopurinol involves the use of anti-inflammatory medications to control the acute symptoms, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Treatment Options for Acute Gout Flare

• Start with an NSAID such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily for 3-5 days if there are no contraindications.
• Alternatively, colchicine 1.2 mg followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until flare resolves is effective if started early, as supported by the guideline 1.
• For patients who cannot take NSAIDs or colchicine, a short course of prednisone 30-40 mg daily for 3-5 days with a taper is appropriate.

Lifestyle Modifications

In addition to managing the acute flare, it's essential to advise patients on lifestyle modifications to prevent future flares, including weight loss if appropriate, avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, and encouragement of low-fat dairy products and regular exercise, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

Monitoring and Adjustment of Allopurinol

After the flare resolves, the allopurinol dose may need adjustment if flares are recurring, with a target serum uric acid level below 6 mg/dL, as recommended by the guideline 1. Gout flares during allopurinol therapy are common, especially in the first 6-12 months of treatment, as urate crystals dissolve from joints, temporarily increasing inflammation. Adequate hydration and avoiding triggers like alcohol and purine-rich foods may help prevent future flares.

From the FDA Drug Label

The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women. While adjusting the dosage of allopurinol tablets in patients who are being treated with colchicine and/or anti-inflammatory agents, it is wise to continue the latter therapy until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months

The patient is already taking allopurinol, and is experiencing a gout flare.

• The patient should continue taking allopurinol as prescribed.
• Anti-inflammatory agents or colchicine should be considered to manage the acute gout flare, and can be continued until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months 2.

From the Research

Management of Gout Flare in Patients Already Taking Allopurinol

• The management of gout flare in patients already taking allopurinol involves several considerations, including the use of anti-inflammatory prophylaxis and the optimization of urate-lowering therapy 3, 4, 5.
• A study published in 2021 found that low-dose colchicine (0.6 mg/day) was associated with a lower rate of adverse events compared to regular-dose colchicine (1.2 mg/day) in patients with gout who were initiated on urate-lowering therapy, including allopurinol 3.
• Another study published in 2025 found that the relationship between gout flare states and patient-reported outcomes was significant, with patients who achieved a patient-acceptable symptom state (PASS) or low disease activity (LDA) having better outcomes than those who did not 4.
• The use of allopurinol in patients with gout is well established, and it is considered a first-line agent for urate-lowering therapy 5.
• However, the timing of allopurinol initiation in patients with acute gout flare is still a topic of debate, with some studies suggesting that early initiation may not lead to significant changes in time to resolution or flare recurrence 6.

Predictors of Gout Flares in Patients Starting Allopurinol

• A study published in 2024 found that predictors of gout flares in patients starting allopurinol using the "start-low go-slow" dose escalation strategy included flare in the month before starting allopurinol, allopurinol 100 mg starting dose, and serum urate ≥0.36 mmol/L at month 6 7.
• The study also found that anti-inflammatory prophylaxis may be best targeted at patients who have had a gout flare in the month before starting allopurinol and are commencing allopurinol 100 mg daily 7.
• The use of colchicine as an anti-inflammatory prophylaxis was also found to be effective in reducing the risk of gout flares in patients starting allopurinol 3, 7.