Should I add allopurinol to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for a patient with hyperuricemia and left heel swelling?

Management of Left Heel Swelling with Hyperuricemia

Allopurinol should not be added to NSAIDs for a patient with uric acid level of 6.68 mg/dL and left heel swelling developing over 6 months, as this does not meet criteria for urate-lowering therapy initiation. 1, 2

Assessment of Current Clinical Picture

The patient presents with:

• Left heel swelling developing gradually over 6 months
• Elevated ESR (inflammatory marker)
• Serum uric acid level of 6.68 mg/dL

Interpretation of Uric Acid Level

• The patient's uric acid level (6.68 mg/dL) is only mildly elevated and below the threshold that strongly indicates gout
• According to current guidelines, asymptomatic hyperuricemia alone is not an indication for allopurinol therapy 1, 2
• The American College of Rheumatology specifically recommends against pharmacological treatment of asymptomatic hyperuricemia 1

Management Approach

Initial Treatment

• NSAIDs are appropriate as first-line therapy for the acute management of potential gout symptoms 1
• For the current presentation:
  • Continue NSAIDs at anti-inflammatory doses
  • Consider a 7-10 day course of NSAIDs (specific dosing depends on the NSAID selected)
  • Ensure adequate hydration (at least 2 liters of fluid daily) 1, 2

When to Consider Allopurinol

Allopurinol should only be initiated if the patient meets specific criteria:

• Confirmed diagnosis of gout (ideally crystal-proven)
• Presence of tophi
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)
• Chronic kidney disease stage ≥3
• History of urolithiasis 1

The FDA label clearly states: "Allopurinol is not recommended for the treatment of asymptomatic hyperuricemia" 2

Diagnostic Considerations

Before considering urate-lowering therapy:

• Confirm diagnosis through joint aspiration and crystal identification if possible
• Rule out other causes of heel swelling (plantar fasciitis, Achilles tendonitis, etc.)
• Monitor uric acid levels over time

Important Cautions

Risks of Inappropriate Allopurinol Use

• Allopurinol is not an innocuous drug 2
• Starting allopurinol during an unconfirmed gout attack without proper indications exposes the patient to unnecessary risks:
  • Allopurinol hypersensitivity syndrome (AHS) - a potentially fatal adverse event 3
  • Bone marrow depression 2
  • Renal function deterioration in predisposed individuals 2

If Allopurinol Becomes Indicated Later

If the patient is eventually diagnosed with gout requiring urate-lowering therapy:

• Start at a low dose (≤100 mg/day, lower in chronic kidney disease) 1
• Gradually titrate to achieve serum urate target of <6 mg/dL 1
• Safe starting dose should not exceed 1.5 mg per unit of estimated GFR to reduce risk of hypersensitivity reactions 3
• Provide anti-inflammatory prophylaxis (colchicine, NSAIDs, or low-dose prednisone) for at least 3-6 months when initiating therapy 1

Conclusion

For this patient with mild hyperuricemia and heel swelling without confirmed gout, continue NSAIDs for symptom management but do not add allopurinol at this time. Further diagnostic workup is needed before considering urate-lowering therapy.