Restarting Allopurinol After Colchicine for Acute Gout
You can start allopurinol immediately during an acute gout attack while taking colchicine—there is no need to wait for the flare to resolve. 1
Evidence-Based Timing for Allopurinol Initiation
Starting During Active Flare (Preferred Approach)
The FDA label explicitly states that colchicine should be given prophylactically when allopurinol is begun, indicating concurrent use is standard practice. 1
Multiple randomized controlled trials demonstrate that initiating allopurinol during an acute gout attack (while on appropriate anti-inflammatory therapy) does not prolong the attack or worsen pain scores. 2, 3
In a 2015 double-blind RCT, patients starting allopurinol during acute gout (within 72 hours of initial therapy) showed no significant difference in days to resolution compared to placebo (15.4 vs 13.4 days, P=0.5). 2
A 2012 RCT found no difference in daily pain scores or subsequent flares when allopurinol 300mg was started immediately versus delayed initiation, with both groups receiving colchicine prophylaxis. 3
Critical Implementation Strategy
Dosing Protocol When Starting Allopurinol
Start allopurinol at 100mg daily and increase by 100mg weekly until serum uric acid reaches <6 mg/dL, without exceeding 800mg daily. 1
Continue colchicine prophylaxis at 0.6mg once or twice daily throughout the titration period. 1, 4
Duration of Colchicine Prophylaxis
Maintain colchicine prophylaxis for at least 6 months after starting allopurinol, or until serum uric acid is normalized AND the patient has been free from acute attacks for several months. 5, 1
Evidence shows that discontinuing prophylaxis at 8 weeks results in a spike in acute attacks (doubling from 20% to 40%), while continuing for 6 months prevents this rebound. 5
A 2004 RCT demonstrated that colchicine prophylaxis for 6 months during allopurinol initiation significantly reduced total flares (0.52 vs 2.91, P=0.008) and flare severity. 4
Practical Considerations
Colchicine Dosing Options
Low-dose colchicine (0.6mg daily) is as effective as regular-dose (1.2mg daily) for flare prophylaxis, with significantly fewer adverse events (8.2% vs 17.9%, P<0.05). 6
For patients with moderate renal impairment or drug interactions, use 0.6mg once daily rather than twice daily. 7
Common Pitfalls to Avoid
Do not delay allopurinol initiation until after the acute flare resolves—this outdated practice unnecessarily postpones definitive therapy and is not supported by current evidence. 2, 3
Do not stop colchicine prophylaxis prematurely—discontinuation before 6 months significantly increases the risk of recurrent flares. 5
Failing to start allopurinol at a low dose (100mg) and titrate gradually increases the risk of precipitating additional flares. 1