What is the recommended dose of allopurinol (Nonsteroidal Anti-Gout (NSAG) medication) for treating a gout attack?

Allopurinol Should NOT Be Used to Treat an Acute Gout Attack

Allopurinol is not indicated for treating an acute gout attack—it is a urate-lowering therapy (ULT) used for long-term prevention of gout flares, not for acute symptom relief. 1, 2

Treatment of Acute Gout Attack

For an active gout attack, the appropriate treatments are:

• Low-dose colchicine (up to 2 mg daily) 1
• NSAIDs 1
• Glucocorticoids (intra-articular, oral, or intramuscular) 1

These anti-inflammatory agents address the acute inflammatory process causing pain and swelling. 1

When to Initiate Allopurinol

Timing Relative to Acute Attack

• Allopurinol can be started during an acute gout attack if the patient is already receiving appropriate anti-inflammatory therapy for the acute flare. 3
• A randomized controlled trial demonstrated that initiating allopurinol at 100 mg daily during an acute treated gout attack did not prolong the attack duration (15.4 days vs 13.4 days placebo, p=0.5). 3
• However, the traditional approach of waiting until the acute attack resolves remains acceptable. 2

Starting Dose and Titration Protocol

Initial dosing:

• Start at 100 mg daily for most patients 1, 4, 2
• Start at 50 mg daily for patients with CKD stage 4 or worse 1, 4
• Even lower doses (≤50 mg/day) should be considered for patients with CKD stage ≥3 1

Titration strategy:

• Increase by 100 mg increments every 2-5 weeks (or weekly per FDA label) until target serum urate <6 mg/dL is achieved 4, 2
• Maximum FDA-approved dose is 800 mg daily 1, 4, 2
• Doses >300 mg should be administered in divided doses 2

Target Serum Urate Levels

• Primary target: <6 mg/dL for all gout patients 4, 2
• Lower target: <5 mg/dL for patients with severe gout (tophi, chronic arthropathy, frequent attacks) 4

Mandatory Prophylaxis When Starting Allopurinol

Anti-inflammatory prophylaxis is essential when initiating allopurinol to prevent gout flares triggered by urate mobilization:

• Colchicine (up to 1.2 mg daily) 1, 2
• NSAIDs (if colchicine contraindicated) 1
• Low-dose glucocorticoids (if both above contraindicated) 1

Duration of prophylaxis: Continue for 3-6 months after initiating ULT, with ongoing evaluation and continuation as needed if flares persist. 4

Common Pitfalls to Avoid

• Do not use allopurinol as monotherapy for acute gout—it will not relieve acute symptoms and may paradoxically trigger more flares if started without prophylaxis. 2
• Do not start at high doses—this increases risk of allopurinol hypersensitivity syndrome (AHS), particularly in patients with CKD. 1
• Do not stop at 300 mg/day without checking serum urate—more than 50% of patients require doses >300 mg/day to achieve target urate levels. 1, 4
• Do not initiate without concurrent anti-inflammatory prophylaxis—acute flares commonly occur during the first months of ULT due to urate mobilization from tissue deposits. 2

Special Considerations for Renal Impairment

• Allopurinol remains the preferred first-line ULT even in moderate-to-severe CKD (stage ≥3). 1, 5
• Dose titration above 300 mg/day is appropriate even with renal impairment when done with careful monitoring. 1, 5, 4, 6
• For creatinine clearance 10-20 mL/min: maximum 200 mg daily 2
• For creatinine clearance <10 mL/min: maximum 100 mg daily 2