From the Guidelines
Allopurinol can be started during a gout attack, but it is crucial to initiate it at a low dose and provide concurrent anti-inflammatory prophylaxis. When deciding to start allopurinol during an acute gout flare, it is essential to consider the patient's overall clinical picture and potential risks. According to the 2020 American College of Rheumatology guideline for the management of gout 1, starting allopurinol during a gout flare is conditionally recommended, emphasizing the importance of concurrent anti-inflammatory prophylaxis. Key points to consider when starting allopurinol during a gout attack include:
- Initiating allopurinol at a low dose, typically ≤100 mg/day, or lower in patients with chronic kidney disease (CKD) 1
- Providing concurrent anti-inflammatory prophylaxis, such as colchicine, NSAIDs, or prednisone/prednisolone, to prevent worsening of the flare 1
- Continuing prophylaxis for 3–6 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares 1 It is also important to note that allopurinol is recommended as the preferred first-line agent for all patients, including those with CKD stage ≥3 1. By following these guidelines and considering the individual patient's needs, allopurinol can be safely started during a gout attack, with the goal of improving morbidity, mortality, and quality of life outcomes.
From the FDA Drug Label
An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained. 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. The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases
- Starting allopurinol during a gout attack is not recommended because it may increase the risk of acute gouty attacks.
- Colchicine or anti-inflammatory agents may be needed to suppress gouty attacks when starting allopurinol.
- It is recommended to start with a low dose of allopurinol (100 mg daily) and increase gradually to minimize the risk of flare-up of acute gouty attacks 2, 2, 2.
From the Research
Starting Allopurinol in a Gout Attack
- The 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on "consensus opinion of experts, case studies, or standard of care" 3.
- A randomized clinical trial found that initiating allopurinol during an acute gout attack did not prolong the acute, treated attack 3.
- The study showed that both intent-to-treat and completer analyses revealed only a statistically insignificant difference in days to resolution (15.4 days in the allopurinol group completers vs 13.4 days in the placebo group; P = 0.5) 3.
- Another study suggests that allopurinol is an agent of first choice for urate lowering therapy, and it can be started during an acute gout attack, but prophylaxis with colchicine or nonsteroidal anti-inflammatory drugs is needed to prevent flares 4, 5.
- It is recommended to initiate allopurinol at low doses during an acute gout attack in patients who meet criteria for starting urate-lowering therapy and do not have abnormal kidney or liver function 3.
- The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 4.
- Reduction of uric acid levels is key to avoiding gout flares, and allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 4, 6.