Should a patient discontinue allopurinol (a xanthine oxidase inhibitor) during a gout flare?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Article Review Status
Submitted
Under Review
Approved

Last updated: March 26, 2025 • View editorial policy

From the Guidelines

No, patients should not discontinue allopurinol during a gout flare, as this can lead to fluctuations in uric acid levels and potentially worsen the situation. The 2020 American College of Rheumatology guideline for the management of gout 1 supports the continuation of allopurinol during a gout flare, emphasizing the importance of maintaining consistent therapy to prevent future attacks.

Key Considerations

  • Allopurinol should be continued without interruption, even during an acute gout attack, to minimize the risk of triggering additional flares.
  • The focus during an acute gout attack should be on treating the inflammation with medications such as colchicine, NSAIDs, or prednisone, while maintaining the allopurinol therapy.
  • If a patient is just starting allopurinol, it's often recommended to delay initiation until 1-2 weeks after the acute attack has resolved, and to start at a low dose (typically 100 mg daily) with gradual increases to reach target uric acid levels, as recommended by the 2020 American College of Rheumatology guideline 1.

Treatment Approach

  • The 2017 updated EULAR evidence-based recommendations for the management of gout 2 suggest that acute flares of gout should be treated as early as possible, with fully informed patients educated to self-medicate at the first warning symptoms.
  • Recommended first-line options for acute flares include colchicine, NSAIDs, or oral corticosteroids, with the choice of drug based on the presence of contraindications, patient experience, and time of initiation after flare onset.
  • Prophylaxis against flares should be fully explained and discussed with the patient, with recommended prophylactic treatment including colchicine or NSAIDs at low dosage, if not contraindicated, as stated in the 2017 EULAR recommendations 2.

Urate-Lowering Therapy

  • The 2020 American College of Rheumatology guideline 1 strongly recommends starting allopurinol at a low dose (≤100 mg/day) with subsequent dose titration to target, and continuing prophylaxis for 3-6 months rather than <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.
  • Allopurinol works by reducing uric acid production, which over time helps prevent future gout attacks, but it takes weeks to months of consistent therapy to achieve this benefit, highlighting the importance of maintaining uninterrupted therapy, as supported by the 2020 guideline 1.

From the FDA Drug Label

The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women. While adjusting the dosage of allopurinol tablets in patients who are being treated with colchicine and/or anti-inflammatory agents, it is wise to continue the latter therapy until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months

No explicit recommendation is provided in the drug label regarding whether a patient should discontinue allopurinol during a gout flare.

  • The label does provide guidance on adjusting the dosage of allopurinol in patients being treated with colchicine and/or anti-inflammatory agents.
  • It is recommended to continue the latter therapy until serum uric acid has been normalized and there has been freedom from acute gouty attacks for several months 3

From the Research

Discontinuing Allopurinol During a Gout Flare

  • The decision to discontinue allopurinol during a gout flare is not explicitly recommended in the provided studies 4, 5, 6, 7, 8.
  • However, it is mentioned that urate-lowering therapy, including allopurinol, should not be introduced or discontinued during an acute episode of gout 7.
  • The goal of gout therapy is to reduce serum uric acid levels, and discontinuing allopurinol during a flare may not be beneficial in achieving this goal 4, 5.
  • Instead, prophylaxis with low-dose colchicine or low-dose NSAIDs may be recommended to prevent acute flares during the initiation of urate-lowering therapy, including allopurinol 6.

Management of Gout Flares

  • The treatment of acute gout flares includes anti-inflammatory therapy, such as NSAIDs, colchicine, and corticosteroids 4, 5, 7, 8.
  • The choice of treatment depends on various factors, including the severity of the flare, comorbidities, and potential drug interactions 5, 7, 8.
  • Prophylaxis with colchicine or NSAIDs may be recommended to prevent acute flares during the initiation of urate-lowering therapy 6.

Urate-Lowering Therapy

  • Allopurinol is a xanthine oxidase inhibitor that is commonly used to reduce serum uric acid levels in patients with gout 4, 5, 7, 8.
  • The dose of allopurinol should be adjusted according to renal function, and a "start low, go slow" strategy may be recommended to reduce the risk of relapses and hypersensitivity syndrome 4.
  • Other urate-lowering therapies, such as febuxostat, uricosuric drugs, and uricolytic drugs, may be considered in patients who are intolerant or unresponsive to allopurinol 4, 5, 8.

References

Research

[Therapy of gout in 2024].

Therapeutische Umschau. Revue therapeutique, 2024

Research

[Treatment of gout].

La Revue de medecine interne, 2011

Research

Clinical manifestations of gout and their management.

The Medical journal of Australia, 2000

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.