Should allopurinol be stopped during a gout flareup?

Should Allopurinol Be Stopped During a Gout Flareup?

No, allopurinol should NOT be stopped during a gout flare—in fact, if a patient is already taking allopurinol when a flare occurs, it should be continued, and if allopurinol is indicated but not yet started, it can be initiated during the acute flare itself. 1

Continue Allopurinol If Already Taking It

• Patients already on allopurinol should continue their current dose during an acute gout flare without interruption. 1, 2
• The traditional practice of stopping urate-lowering therapy during flares is no longer recommended and may lead to delayed appropriate therapy. 2
• Continuing allopurinol maintains steady urate-lowering effects and prevents fluctuations in serum urate that could potentially trigger additional flares. 1

Starting Allopurinol During an Active Flare

The 2020 American College of Rheumatology guidelines conditionally recommend starting allopurinol during a gout flare rather than waiting for the flare to resolve, based on several key considerations: 1

Evidence Supporting Initiation During Flares

• Two randomized controlled trials demonstrated that starting allopurinol during an acute gout attack does not significantly prolong flare duration or worsen severity compared to delayed initiation. 1, 3, 4
• In one trial of 51 patients, mean daily pain scores showed no significant difference between those starting allopurinol 300 mg during the flare versus placebo, with pain declining similarly in both groups over 10 days. 4
• Another trial of 31 patients found only a statistically insignificant difference in days to resolution (15.4 days with allopurinol versus 13.4 days with placebo). 3

Practical Benefits of Starting During Flares

• Time efficiency: Initiating therapy during the flare visit prevents the risk of patients not returning for delayed initiation. 1
• Patient motivation: Patients experiencing acute symptoms are highly motivated to start long-term preventive therapy. 1
• Earlier disease control: Starting sooner addresses the underlying hyperuricemia without unnecessary delay. 2

Critical Requirements When Starting or Continuing Allopurinol During a Flare

Mandatory Anti-Inflammatory Prophylaxis

Concomitant anti-inflammatory prophylaxis is strongly recommended when initiating allopurinol, regardless of whether started during or after a flare. 1

• Options include colchicine (0.5-1 mg daily), NSAIDs, or prednisone/prednisolone. 1
• Prophylaxis should be continued for 3-6 months after starting allopurinol, not just until the current flare resolves. 1
• Colchicine prophylaxis reduces both the frequency (0.52 versus 2.91 flares) and severity of acute flares when starting allopurinol. 5

Proper Dosing Strategy

• Start at a low dose (100 mg daily for most patients, or 50 mg daily in CKD stage ≥4) even when initiating during a flare. 1
• Gradual dose titration every 2-5 weeks is strongly recommended over starting at higher doses to minimize flare risk. 1
• The goal is to achieve serum urate <6 mg/dL through dose escalation, often requiring 300-600 mg daily. 1

Treat the Flare Appropriately While Continuing/Starting Allopurinol

• The acute flare itself requires separate anti-inflammatory treatment (NSAIDs, colchicine, or corticosteroids at therapeutic doses for flare management). 1
• This acute flare treatment is distinct from the prophylactic anti-inflammatory therapy used to prevent future flares during allopurinol initiation. 1

Common Pitfalls to Avoid

• Do not stop allopurinol during a flare if the patient is already taking it—this outdated practice can cause serum urate fluctuations. 2
• Do not delay starting allopurinol until after complete flare resolution if the patient meets criteria for urate-lowering therapy. 2
• Do not start allopurinol during a flare without anti-inflammatory prophylaxis—this significantly increases the risk of subsequent flares. 1, 5
• Do not confuse acute flare treatment with prophylaxis—patients need both therapeutic doses for the current flare AND prophylactic doses to prevent future flares. 1

Special Considerations

• While the evidence supports starting during flares, this is a conditional recommendation, meaning individual patient factors may reasonably support delaying initiation in some cases (e.g., concerns about medication complexity or patient preference). 1
• The supporting trials used allopurinol doses of 200-300 mg, so these findings may not generalize to more potent urate-lowering strategies or higher initial doses. 1