Should I take allopurinol during a gout flare?

Allopurinol Should Not Be Started During an Acute Gout Flare Without Prophylaxis

Do not take allopurinol alone during an acute gout flare. Instead, focus on treating the flare first with anti-inflammatory medications, and only start allopurinol with proper anti-inflammatory prophylaxis. 1

Management of Acute Gout Flare

First Priority: Treat the Acute Flare

• Focus on anti-inflammatory medications to address the current pain and inflammation 1
• Options include colchicine, NSAIDs, or corticosteroids depending on your medical history and contraindications 1

When to Start Allopurinol

• The 2020 American College of Rheumatology guidelines conditionally recommend that allopurinol can be started during a gout flare (rather than waiting until it resolves) 1
• However, this recommendation comes with a critical requirement: anti-inflammatory prophylaxis must be used concurrently 1

Proper Approach to Starting Allopurinol

Required Concurrent Prophylaxis

• Anti-inflammatory prophylaxis is strongly recommended when initiating allopurinol (whether during or after a flare) 1, 2
• Options for prophylaxis include:
  • Colchicine (0.5-1mg daily) 2, 3
  • NSAIDs (if not contraindicated) 1
  • Low-dose prednisone/prednisolone 1

Duration of Prophylaxis

• Continue prophylaxis for 3-6 months after starting allopurinol 1
• This extended duration is necessary because flares commonly occur during the initial months of urate-lowering therapy 3

Proper Allopurinol Dosing

• Start with a low dose (100mg daily) 4
• Gradually increase by 100mg increments every 2-4 weeks until target serum urate level is reached 2, 4
• Target serum urate level should be <6 mg/dL 1

Research Evidence on Starting During Flares

• Multiple studies have shown that starting allopurinol during an acute flare does not significantly prolong the flare duration when proper prophylaxis is used 5, 6, 7
• A randomized clinical trial found no significant difference in pain scores or flare duration between early versus delayed allopurinol initiation 6
• Another study showed that with proper prophylaxis, allopurinol initiation during a flare did not lead to longer resolution time 7

Common Pitfalls to Avoid

• Never start allopurinol without anti-inflammatory prophylaxis during or immediately after a flare 1
• Avoid high initial doses of allopurinol (start at 100mg or lower if you have kidney disease) 1, 4
• Don't stop prophylaxis too early (less than 3 months) as this increases risk of flares 1
• Don't rely on allopurinol alone to treat an active flare - it won't help with current pain 1

Long-term Management

• Once started, allopurinol should be continued long-term with dose adjustments to maintain serum urate <6 mg/dL 1
• Regular monitoring of serum urate levels is essential to ensure proper dosing 1
• Lifelong therapy is typically required to prevent recurrent flares 2