From the Guidelines
It is conditionally recommended to start allopurinol during a gout flare, rather than waiting for the flare to resolve. This approach is supported by the 2020 American College of Rheumatology guideline for the management of gout 1. When starting allopurinol during a gout flare, it is essential to initiate concomitant anti-inflammatory prophylaxis therapy, such as colchicine, NSAIDs, or prednisone/prednisolone, to prevent worsening of the flare 1.
Key Considerations
- The dose of allopurinol should be started low, typically less than 100 mg/day, and titrated to target over time, especially in patients with chronic kidney disease (CKD) stage >3 1.
- The choice of specific anti-inflammatory prophylaxis should be based on patient factors, and prophylaxis should be continued for 3-6 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares 1.
- Starting allopurinol during a gout flare may potentially worsen or prolong the attack, but the benefits of initiating urate-lowering therapy outweigh the risks, and prophylactic medication can help mitigate these effects 1.
Treatment Approach
- Initiate allopurinol at a low dose during the gout flare
- Start concomitant anti-inflammatory prophylaxis therapy
- Titrate the allopurinol dose to target over time
- Continue prophylaxis for 3-6 months, with ongoing evaluation and continued prophylaxis as needed.
From the FDA Drug Label
To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage.
It is not recommended to start allopurinol during a gout flare. The drug label suggests that allopurinol can cause an increase in acute attacks of gout, especially when initiated at a high dose. Instead, the recommended approach is to start with a low dose and gradually increase it to minimize the risk of flare-ups. Therefore, it is best to wait until the gout flare has resolved before initiating allopurinol therapy 2.
From the Research
Allopurinol Initiation During Gout Flare
- The 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack 3.
- A 2015 study found that initiating allopurinol at low doses during an acute gout attack did not prolong the acute, treated attack 3.
- A 2022 randomized controlled trial compared early and late allopurinol initiation in acute gout flare and found no significant difference in time to complete resolution of acute gout flare between the two groups 4.
- Another study in 2024 found that predictors of gout flare when commencing allopurinol include flare in the month before starting allopurinol and allopurinol 100 mg starting dose 5.
Clinical Characteristics and Health Care Utilization
- A 2013 population-based cohort study described the clinical characteristics and health care utilization patterns in patients with gout who were newly prescribed allopurinol, febuxostat, or colchicine 6.
- The study found that patients who started allopurinol, febuxostat, or colchicine for gout generally had hyperuricemia and multiple comorbidities 6.
- A 2022 review discussed the treatment of gout flares and lowering serum urate, including the use of allopurinol as an agent of first choice for urate lowering therapy 7.
Key Findings
- Allopurinol can be initiated during an acute gout attack without prolonging the attack 3, 4.
- Predictors of gout flare when commencing allopurinol include flare in the month before starting allopurinol and allopurinol 100 mg starting dose 5.
- Patients with gout often have multiple comorbidities and high health care utilization 6.
- Allopurinol is an effective urate lowering therapy, but screening for HLA*B58:01 mutation is recommended in certain populations to decrease the occurrence of allopurinol hypersensitivity syndrome 7.