Allopurinol Should Not Be Stopped Abruptly
Allopurinol should be tapered gradually rather than stopped abruptly to prevent acute gout flares, with dose reductions of 50-100 mg every 2-4 weeks until complete discontinuation. 1
Proper Tapering Protocol
When discontinuing allopurinol, follow this structured approach:
- Initial tapering: Reduce dose by 50-100 mg every 2-4 weeks
- Higher doses: For patients on >300 mg/day, use longer tapering periods
- Monitoring: Check serum uric acid levels every 2-4 weeks during tapering
- Post-discontinuation: Monitor for rebound hyperuricemia 2-4 weeks after complete discontinuation 1
Flare Prevention During Tapering
To minimize risk of gout flares during discontinuation:
- Consider prophylactic colchicine (0.5-1.0 mg daily) during tapering and for 3-6 months after discontinuation
- Alternative: Low-dose NSAIDs with gastroprotection if colchicine is contraindicated
- Monitor for signs of gout flare (joint pain, swelling, redness) 1
Special Situations Requiring Immediate Discontinuation
In certain circumstances, allopurinol should be stopped immediately without tapering:
- Severe adverse reactions (per FDA label, patients with severe reactions should not be restarted on the drug) 2
- Pregnancy (planned or suspected) due to potential risk of fetal abnormalities 1
Drug Interactions Requiring Adjustment
If a patient is taking azathioprine or mercaptopurine concurrently with allopurinol:
- These medications will need dose adjustment when allopurinol is discontinued
- Gradually increase to standard dosing after allopurinol is completely discontinued 1
- For patients with inflammatory bowel disease on combination therapy, special monitoring may be needed 3
Long-Term Outcomes After Discontinuation
Research shows significant consequences of stopping allopurinol:
- Gout relapse rates are high (36-81%) after discontinuation 4
- Relapses typically occur 1-4.5 years after ULT discontinuation 4
- Patients with lower serum urate levels before and after discontinuation may have lower recurrence rates 4
Common Reasons for Non-Adherence
Understanding why patients stop allopurinol can help prevent inappropriate discontinuation:
- Desire to lead a normal life (23% of patients)
- Wanting to think of themselves as healthy again (20%)
- Testing if they really need the medication (22%) 5
- Experiencing gout flares while on allopurinol (due to misunderstanding that flares can occur during initial therapy) 6
Clinical Pitfalls to Avoid
- Abrupt discontinuation: Can trigger acute gout flares
- Inadequate monitoring: Failure to check uric acid levels during and after tapering
- Overlooking drug interactions: Especially with azathioprine/mercaptopurine which require dose adjustments
- Insufficient patient education: Not explaining that temporary flares during initiation don't indicate treatment failure 6