From the Guidelines
Allopurinol should not be used to treat acute gout, but rather as a long-term urate-lowering therapy to prevent future attacks, starting at a low dose of 100mg daily and gradually increasing by 100mg every 2-4 weeks to reach a target serum uric acid level below 6mg/dL, with typical maintenance doses of 300-600mg daily, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. For acute gout, first-line treatments include NSAIDs (such as naproxen 500mg twice daily or indomethacin 50mg three times daily for 3-5 days), colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until flare resolves), or corticosteroids (prednisone 30-40mg daily, tapered over 7-10 days) 1. Key points to consider in the management of gout include:
- Initiating urate-lowering therapy for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 1
- Using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day) 1
- A treat-to-target management strategy with ULT dose titration guided by serial serum urate measurements, with an SU target of <6 mg/dl 1
- Concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months when initiating ULT 1
- Lifestyle modifications including weight loss, limiting alcohol intake, avoiding high-purine foods, and adequate hydration are important adjuncts to medication 1. It is essential to note that allopurinol is not used to treat acute gout attacks but is instead used as a long-term urate-lowering therapy to prevent future attacks, and its use should be guided by the latest clinical guidelines and patient-specific factors, as outlined in the 2020 American College of Rheumatology guideline for the management of gout 1.
From the FDA Drug Label
Allopurinol tablets reduce serum and urinary uric acid concentrations. The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. 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.
Allopurinol in Acute Gout: Allopurinol is not recommended for the treatment of acute gout attacks. Instead, it is used for the management of patients with signs and symptoms of primary or secondary gout.
- The recommended dosage is to start with a low dose of allopurinol (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 of 800 mg daily 2.
- It is also recommended to use colchicine or anti-inflammatory agents to suppress gouty attacks in some cases 2.
- Key Considerations:
From the Research
Acute Gout Management
- The management of acute gout involves the use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), colchicine, and corticosteroids to reduce pain and inflammation 3, 4.
- According to the 2012 American College of Rheumatology Guidelines for the Management of Gout, urate-lowering therapy can be started during an acute attack, based on "consensus opinion of experts, case studies, or standard of care" 5.
- A study published in 2015 found that initiating allopurinol during an acute gout attack did not prolong the acute, treated attack in patients who met criteria for starting urate-lowering therapy and did not have abnormal kidney or liver function 5.
Urate-Lowering Therapy
- Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares by reducing serum uric acid levels 6, 4.
- The goal of urate-lowering therapy is to achieve a target serum uric acid level, and treatment should be escalated until this target is reached 6.
- Allopurinol is a commonly used urate-lowering therapy, and its use has been studied in several clinical trials 5, 4.
Prophylaxis of Acute Gout
- Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy to prevent acute gouty arthritis for a period of at least 6 months 3.
- A study published in 2021 found that low-dose colchicine (0.6 mg/day) was as effective as regular-dose colchicine (1.2 mg/day) in preventing gout flares in patients initiated on urate-lowering therapies, with fewer adverse events 7.