Can I discontinue allopurinol (Zyloprim)?

From the Guidelines

I strongly advise against discontinuing allopurinol without consulting your healthcare provider first, as it can lead to acute gout flares or other complications. Allopurinol is typically prescribed for conditions like gout or kidney stones to lower uric acid levels in your body, and stopping it suddenly can trigger a recurrence of symptoms. According to the 2020 American College of Rheumatology guideline for the management of gout 1, allopurinol is recommended as the preferred first-line agent for all patients, including those with moderate-to-severe CKD.

The guideline suggests that treatment with allopurinol should be started at a low dose and titrated upward until the target serum urate level is reached, and that this level should be maintained lifelong to prevent recurrence of flares. A study published in the Annals of the Rheumatic Diseases in 2017 also recommends maintaining a serum urate level of <6 mg/dL lifelong to prevent recurrence of flares 1.

Some key points to consider when taking allopurinol include:

• Starting treatment with a low dose and titrating upward to minimize the risk of flare associated with initiation
• Maintaining a serum urate level of <6 mg/dL to prevent recurrence of flares
• Regular monitoring of serum urate levels to ensure that the target level is being maintained
• Consulting with your healthcare provider before making any changes to your medication regimen

If you're experiencing side effects or have concerns about your medication, it's essential to schedule an appointment with your doctor to discuss these issues. They may adjust your dose, switch you to a different medication like febuxostat, or provide guidance on safely discontinuing if appropriate. Remember that allopurinol is usually a long-term medication that helps prevent painful gout attacks and joint damage by consistently keeping uric acid levels under control. Stopping it can allow these levels to rise again, potentially causing symptoms to return or worsen.

From the FDA Drug Label

ALLOPURINOL TABLETS SHOULD BE DISCONTINUED AT THE FIRST APPEARANCE OF SKIN RASH OR OTHER SIGNS WHICH MAY INDICATE AN ALLERGIC REACTION Patients should be informed of the following: (1) They should be cautioned to discontinue allopurinol tablets and to consult their physician immediately at the first sign of a skin rash, painful urination, blood in the urine, irritation of the eyes, or swelling of the lips or mouth

Discontinuation of allopurinol (Zyloprim) is recommended in certain situations, such as:

• At the first appearance of a skin rash or other signs of an allergic reaction
• If a patient experiences a severe hypersensitivity reaction, such as Stevens-Johnson syndrome or generalized vasculitis
• If a patient develops signs of liver damage, such as anorexia, weight loss, or pruritus

However, the decision to discontinue allopurinol should be made under the guidance of a physician, as it may be necessary to continue treatment to control gouty attacks. 2 2

From the Research

Discontinuing Allopurinol

To address the question of whether one can discontinue allopurinol (Zyloprim), it's essential to consider the context and purpose of its use. Allopurinol is primarily prescribed for the management of gout, a condition characterized by elevated levels of uric acid in the blood, leading to joint pain and inflammation.

Reasons for Discontinuation

• Lack of Efficacy: If allopurinol is not effectively managing gout symptoms or reducing uric acid levels, a healthcare provider might consider alternative treatments.
• Side Effects: Adverse reactions to allopurinol, such as rash, nausea, or more severe conditions like allopurinol hypersensitivity syndrome, could necessitate discontinuation.
• Dose Adjustment: Studies have shown that the standard dose of allopurinol may not be sufficient for all patients, and dose escalation may be necessary to achieve optimal uric acid levels 3. However, this does not directly address discontinuation but rather adjustment.

Considerations Before Discontinuation

• Alternative Therapies: The decision to discontinue allopurinol should consider the availability and suitability of alternative urate-lowering therapies, such as febuxostat 4, 5.
• Safety Profile: Allopurinol has a well-established safety profile, especially when compared to other urate-lowering drugs 5, 6. Discontinuation should weigh the risks and benefits, particularly in patients with a history of cardiovascular events.
• Gout Management: For patients with chronic gout, discontinuing allopurinol without an alternative management plan could lead to an increase in gout attacks and worsening of the condition.

Key Points

• Discontinuation of allopurinol should be considered under the guidance of a healthcare provider.
• Alternative therapies and their potential side effects should be evaluated.
• The decision to discontinue should be based on individual patient needs and the presence of side effects or lack of efficacy.
• Studies have shown that allopurinol is generally safe and effective for the management of gout, but individual responses may vary 7, 3, 6.

Evidence Summary

• Allopurinol is effective in managing gout but may require dose adjustment for optimal efficacy 7, 3.
• The safety of allopurinol compared to other urate-lowering therapies has been established, with a favorable profile 4, 5.
• Discontinuation without a clear reason or alternative plan may not be advisable, given the potential for gout exacerbation.