Is it appropriate to start allopurinol in a patient with gout who is not responding to colchicine?

Management of Gout in a Patient with Colchicine-Resistant Flares

Yes, it is appropriate to start allopurinol in a patient with gout who is not responding to colchicine for flares. 1

Understanding the Distinction Between Treatments

• Colchicine is used for acute flare management and prophylaxis, while allopurinol is a urate-lowering therapy (ULT) that addresses the underlying cause of gout by reducing serum uric acid levels 1
• These medications serve different purposes in gout management - colchicine treats/prevents flares while allopurinol prevents future flares by lowering uric acid 1

Indications for Starting Allopurinol

• Allopurinol should be considered and discussed with every patient with a definite diagnosis of gout from the first presentation 1
• ULT is strongly indicated in patients with:
  • Recurrent flares (including those not responding adequately to colchicine) 1
  • Presence of tophi 1
  • Urate arthropathy and/or renal stones 1
  • Radiographic damage attributable to gout 1

Initiation Protocol for Allopurinol

• Start with a low dose (100 mg/day, or lower in patients with renal impairment) 1, 2
• Gradually increase by 100 mg increments every 2-4 weeks until reaching the target serum uric acid level of <6 mg/dL (360 μmol/L) 1, 2
• The average effective dose is 200-300 mg/day for mild gout and 400-600 mg/day for moderately severe tophaceous gout 2
• Maximum recommended dosage is 800 mg daily 2

Critical Prophylaxis When Starting Allopurinol

• Always initiate concomitant anti-inflammatory prophylaxis when starting allopurinol to prevent paradoxical flares 1, 2
• Prophylactic options include:
  • Colchicine (0.5-1.2 mg daily, with dose reduction in renal impairment) 1
  • NSAIDs (if colchicine is contraindicated or not tolerated) 1
  • Low-dose oral corticosteroids (if both colchicine and NSAIDs are contraindicated) 1
• Continue prophylaxis for 3-6 months after starting allopurinol 1, 3

Monitoring and Follow-up

• Monitor serum uric acid levels to ensure target of <6 mg/dL (360 μmol/L) is achieved 1
• A lower target (<5 mg/dL; 300 μmol/L) may be appropriate for patients with severe gout until resolution of tophi and gout attacks 1
• Once target is reached, maintain lifelong ULT to prevent recurrence 1

Common Pitfalls to Avoid

• Starting with too high a dose of allopurinol increases risk of hypersensitivity reactions and flares 1, 2
• Failing to provide prophylaxis when initiating allopurinol can lead to painful flares that reduce medication adherence 3, 4
• Inadequate dose titration - many patients remain on initial doses without appropriate escalation to reach target uric acid levels 5
• Not recognizing that early flares during allopurinol initiation are expected and don't indicate treatment failure 2

Special Considerations

• For patients with renal impairment, start with lower doses (50-100 mg) and monitor closely 1, 2
• If allopurinol is started during an acute flare, ensure adequate treatment of the flare is maintained 6
• Recent evidence suggests starting allopurinol during an acute flare does not significantly prolong flare duration when appropriate anti-inflammatory treatment is given 6

Remember that colchicine resistance for flares indicates the need for a different approach to gout management, and allopurinol addresses the underlying cause by reducing uric acid levels rather than just treating symptoms.