Allopurinol Should NOT Be Used to Treat Acute Gout Attacks
Allopurinol has no role in treating the pain and inflammation of an acute gout attack—it is a urate-lowering therapy for long-term prevention, not an acute anti-inflammatory agent. For acute gout, you must use corticosteroids, NSAIDs, or colchicine 1.
Treatment of Acute Gout Attack
First-line therapy for acute gout should be:
- Corticosteroids (oral, intra-articular, or intramuscular) 1
- NSAIDs (any NSAID is effective as a class) 1
- Low-dose colchicine (1.2 mg initially, then 0.6 mg after 1 hour—NOT the old high-dose regimen) 1
Corticosteroids are generally preferred as first-line when no contraindications exist because they are safer and lower cost 1. The choice among these three depends on patient comorbidities and contraindication profiles 1.
Can Allopurinol Be STARTED During an Acute Attack?
Yes, allopurinol can be initiated during an acute gout attack, but ONLY if you simultaneously treat the acute inflammation and provide prophylaxis. This is a critical distinction from using allopurinol to treat the attack itself.
Evidence for Starting Allopurinol During Acute Flare:
- The American College of Rheumatology guidelines indicate that urate-lowering therapy can be started during an acute attack 2
- Two randomized trials demonstrated that initiating allopurinol during an acute attack (with appropriate anti-inflammatory treatment) does NOT prolong the attack 3, 4
- In one trial of 57 patients, starting allopurinol 300 mg daily versus placebo showed no difference in daily pain scores or subsequent flares when both groups received indomethacin and prophylactic colchicine 4
- Another trial of 31 patients found no significant difference in days to resolution (15.4 days with allopurinol vs 13.4 days with placebo, p=0.5) 3
Mandatory Requirements When Starting Allopurinol During Acute Attack:
You MUST provide anti-inflammatory prophylaxis with colchicine or NSAIDs when initiating allopurinol 2, 1:
- Colchicine 0.5-0.6 mg once or twice daily 2, 1
- Continue prophylaxis for at least 3-6 months after reaching target uric acid levels 2, 1
- High-quality evidence shows prophylaxis reduces acute flares by more than 50% when starting urate-lowering therapy 1
- Prophylaxis should continue for more than 8 weeks minimum 1
When Is Allopurinol Actually Indicated?
Allopurinol is indicated for long-term management in patients with 1:
- Recurrent acute attacks (≥2 episodes per year)
- Presence of tophi
- Chronic gouty arthropathy or radiographic changes
- History of nephrolithiasis
- Urate overproduction
Allopurinol Dosing Strategy:
- Start at 100 mg daily and increase by 100 mg every 2-4 weeks 1
- Target serum uric acid <6.0 mg/dL (360 μmol/L) 1
- Most patients achieve target with 300 mg/day, but doses up to 600 mg/day may be needed and are safe with normal renal function 5, 6
- Dose must be adjusted in renal impairment 1, 7
Critical Pitfalls to Avoid:
Never use allopurinol as monotherapy for an acute attack—it will not relieve pain and may paradoxically worsen the flare if started without prophylaxis 7
Never start allopurinol without concurrent anti-inflammatory prophylaxis—this dramatically increases the risk of precipitating additional acute attacks 8, 1
Do not start allopurinol after a first gout attack or in patients with infrequent attacks (<2/year)—the risks outweigh benefits in these populations 9
Watch for allopurinol hypersensitivity syndrome (DRESS)—discontinue immediately if rash develops, as severe reactions can be fatal 7
Remember that urate-lowering therapy does NOT reduce acute attack risk in the first 6 months—it may actually increase flares initially, which is why prophylaxis is essential 1