What medication is contraindicated during the acute phase of a newly diagnosed case of gout?

Allopurinol is Contraindicated During Acute Gout Flares

In a newly diagnosed case of gout presenting with an acute flare, allopurinol (option C) is contraindicated as the initial treatment. While NSAIDs, colchicine, and corticosteroids are all appropriate first-line treatments for acute gout attacks, initiating urate-lowering therapy with allopurinol during an acute flare has traditionally been avoided.

First-Line Treatments for Acute Gout Flares

The American College of Physicians and European League Against Rheumatism (EULAR) guidelines recommend the following medications for acute gout attacks:

1. NSAIDs (Option A) - Effective first-line therapy for acute gout flares when used at full anti-inflammatory doses 1

2. Colchicine (Option B) - Recommended at low doses (1.2 mg followed by 0.6 mg one hour later) for acute gout attacks 2, 1

3. Corticosteroids (Option D) - Dexamethasone is an appropriate treatment option for acute gout, especially in patients with contraindications to NSAIDs or colchicine 1

Why Allopurinol is Contraindicated in Acute Gout

Allopurinol is a urate-lowering therapy (ULT) that works by inhibiting xanthine oxidase, thereby reducing serum uric acid production. According to the 2012 American College of Rheumatology guidelines:

1. Allopurinol is indicated for long-term management of hyperuricemia, not for acute symptom relief 2

2. Initiating ULT during an acute attack can potentially worsen or prolong the acute flare 2

3. The primary goal during an acute attack is to reduce inflammation and pain, not to lower uric acid levels 1

Proper Timing for Initiating Allopurinol

Traditionally, allopurinol has been started after the complete resolution of an acute gout attack. While some recent smaller studies suggest that allopurinol initiation during an acute attack might not significantly prolong flare duration 3, 4, these studies had limited sample sizes (31 and 51 patients respectively) and the guidelines still generally recommend waiting.

The 2016 updated EULAR recommendations state:

"The task force did not give specific guidance on whether urate-lowering drugs should be initiated during a flare or whether a traditional 2 weeks delay from flare termination should be observed... the task force considered that the low number of patients in these trials precluded any firm conclusions and that data obtained with allopurinol 200–300 mg could not be generalised to more potent urate-lowering drugs." 2

Proper Protocol for Starting Allopurinol (When Appropriate)

When allopurinol is eventually initiated for patients with recurrent gout:

1. Start at a low dose (≤100 mg/day) 2

2. Gradually titrate upward every 2-5 weeks until target serum urate levels are achieved 2

3. Provide prophylaxis against acute flares with colchicine or low-dose NSAIDs for 3-6 months after starting allopurinol 1, 5

Conclusion

For a newly diagnosed case of gout presenting with an acute flare, the contraindicated medication is allopurinol (Option C). Treatment should focus on resolving the acute inflammation with NSAIDs, colchicine, or corticosteroids before considering urate-lowering therapy for long-term management.