From the Guidelines
Yes, allopurinol should be continued during an acute gout attack. The 2016 updated EULAR evidence-based recommendations for the management of gout suggest that urate-lowering therapy (ULT) should be maintained during acute flares 1. If a patient is already taking allopurinol when a gout flare occurs, they should maintain their current dose without interruption. For patients not yet on allopurinol, it's generally recommended to wait until the acute attack resolves before initiating therapy, typically starting at a low dose and gradually increasing to reach target serum uric acid levels below 6 mg/dL 1.
Key Considerations
- During an acute attack, the focus should be on anti-inflammatory treatments such as colchicine, NSAIDs, or corticosteroids to manage pain and inflammation 1.
- Stopping allopurinol during an attack can actually prolong the flare or trigger additional attacks due to fluctuations in serum uric acid levels.
- Allopurinol works by inhibiting xanthine oxidase, which reduces uric acid production, while the acute attack is driven by an inflammatory response to existing urate crystals 1.
- These are separate processes, making it safe and beneficial to continue urate-lowering therapy while treating the acute inflammation.
Management Approach
- For acute flares, recommended first-line options include colchicine, NSAIDs, or oral corticosteroids 1.
- Prophylaxis against flares should be considered during the first 6 months of ULT, with colchicine being a recommended prophylactic treatment 1.
- The goal of ULT is to maintain serum uric acid levels below 6 mg/dL, with adjustments made as necessary to achieve this target 1.
From the FDA Drug Label
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
Continue allopurinol during an acute gout attack, as the drug label recommends continuing the therapy until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months 2.
From the Research
Allopurinol Use During Acute Gout Attack
- The management of gout involves the use of non-steroidal anti-inflammatory drugs, colchicine, and corticosteroids for acute attacks, while allopurinol is used for reducing uric acid concentrations 3.
- A study found that initiating allopurinol during an acute gout attack did not prolong the painful arthritis, suggesting that it can be started during an acute attack in patients who meet criteria for starting urate-lowering therapy and do not have abnormal kidney or liver function 4.
- The efficacy and tolerability of allopurinol dose escalation in patients with gout have been investigated, with results showing that most patients can attain target serum uric acid concentrations with doses of 300 mg/day, but some may require higher doses up to 600 mg/day 5.
- When starting allopurinol therapy, prophylaxis with colchicine or NSAIDs is needed to prevent acute gout, with colchicine being preferable in some cases due to its lower cost and better tolerability 6.
- The American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on expert opinion and case studies 4.
Considerations for Continuing Allopurinol
- Allopurinol is an effective treatment for reducing uric acid concentrations and can be continued during an acute gout attack, as it does not prolong the painful arthritis 4.
- The dose of allopurinol may need to be adjusted based on renal function and serum uric acid concentrations, with higher doses potentially required to achieve target levels 7, 5.
- Prophylaxis with colchicine or NSAIDs should be considered when starting allopurinol therapy to prevent acute gout, especially in patients with a history of gouty attacks 6.