Can allopurinol be taken during an acute gout attack?

Allopurinol During Acute Gout Attack

Allopurinol can be safely initiated during an acute gout attack without prolonging the duration or severity of the flare, provided that appropriate anti-inflammatory prophylaxis is used concurrently. 1, 2, 3, 4

Evidence for Starting Allopurinol During Acute Flare

The traditional practice of delaying allopurinol initiation until after resolution of an acute gout attack has been challenged by recent evidence:

• The 2020 American College of Rheumatology (ACR) guideline explicitly states: "When the decision is made that ULT is indicated while the patient is experiencing a gout flare, we conditionally recommend starting ULT during the gout flare." 1

• Multiple randomized controlled trials have demonstrated that starting allopurinol during an acute gout attack does not prolong the attack:

  • A 2015 study showed no significant difference in days to resolution between patients starting allopurinol versus placebo during acute gout (15.4 vs 13.4 days, p=0.5) 2
  • A 2012 trial found no difference in daily pain scores or subsequent flares when allopurinol was initiated during acute attacks 3
  • A 2022 randomized controlled trial comparing early versus late allopurinol initiation found no significant difference in time to complete resolution (median 6 days in both groups) 4

Prophylaxis Requirements

When starting allopurinol during an acute attack, proper anti-inflammatory prophylaxis is essential:

• The FDA drug label for allopurinol states: "An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets... Accordingly, maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun." 5

• Prophylactic options include:

  • Low-dose colchicine (0.6 mg once or twice daily)
  • Low-dose NSAIDs with gastroprotection if indicated
  • Low-dose prednisone/prednisolone 6

• Prophylaxis should be continued for 3-6 months after achieving target urate levels 1, 6

Proper Allopurinol Initiation Protocol

1. Starting dose: Begin with 100 mg daily (or 50 mg daily in patients with CKD stage 4 or worse) 6, 5

2. Dose titration: Increase by 100 mg every 2-4 weeks until target uric acid level is reached (<6 mg/dL or <360 μmol/L) 6

3. Concurrent prophylaxis: Administer anti-inflammatory prophylaxis (colchicine, NSAIDs, or low-dose corticosteroids) to prevent flares during initiation 1, 6

4. Monitoring: Check serum uric acid levels every 2-4 weeks during dose titration 6

Common Pitfalls to Avoid

1. Inadequate prophylaxis: Failure to provide anti-inflammatory prophylaxis when starting allopurinol significantly increases the risk of flares 1, 7

2. Discontinuing allopurinol during flares: Stopping allopurinol during acute attacks can lead to fluctuations in uric acid levels and potentially worsen the long-term disease course 6

3. Underdosing: Starting and maintaining allopurinol at low doses without titration often fails to achieve target uric acid levels. A study showed that increasing allopurinol to 600 mg/day (when needed) achieved target levels in 92.5% of patients versus only 70.4% at 300 mg/day 8

4. Insufficient duration of prophylaxis: Evidence shows that prophylaxis should be continued for at least 3-6 months, with longer durations being more effective than shorter ones 1

By following these evidence-based recommendations, allopurinol can be safely and effectively initiated during an acute gout attack, potentially streamlining treatment and improving long-term outcomes for patients with gout.