What is the management plan for acute gouty arthritis in the left foot with severe pain, elevated uric acid level, and potential treatment with Allopurinol (zyloprim)?

From the Guidelines

I strongly recommend that you seek immediate medical attention for your acute gout flare, as delaying treatment can lead to prolonged pain and potential long-term damage. While Allopurinol is used for long-term gout management, it's not appropriate for treating an active, painful flare. Instead, you need anti-inflammatory medications like colchicine, NSAIDs (such as naproxen or indomethacin), or corticosteroids to reduce the severe inflammation causing your pain, as recommended by the American College of Physicians 1. For immediate relief, rest your foot, apply ice for 20-30 minutes several times daily, elevate it when possible, and drink plenty of water. Your uric acid level of 5.5 is actually within normal range, but this doesn't rule out gout as levels often fluctuate and can be normal during an acute attack. Once this flare resolves, your doctor may consider starting Allopurinol for long-term prevention, especially if you have recurrent attacks, but this medication takes weeks to become effective and can actually worsen symptoms if started during an active flare, as noted in the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Given your pain level of 8/10 and difficulty walking, you should be evaluated promptly rather than waiting for a routine appointment. Some key points to consider include:

• The importance of treating acute gout flares promptly to reduce pain and prevent long-term damage
• The use of anti-inflammatory medications, such as colchicine, NSAIDs, or corticosteroids, to reduce inflammation and pain
• The role of Allopurinol in long-term gout management, but not in treating active flares
• The need for lifestyle modifications, such as weight loss, dietary changes, and reduced alcohol consumption, to help manage gout, as recommended by the EULAR guidelines 1. It's also important to note that the management of gout should be individualized, taking into account the patient's specific needs and circumstances, as emphasized in the systematic review in support of an American College of Physicians clinical practice guideline 1.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage. Normal serum urate levels are usually achieved in 1 to 3 weeks The upper limit of normal is about 7 mg/dL for men and postmenopausal women and 6 mg/dL for premenopausal women.

The patient's uric acid level is 5.5, which is below the upper limit of normal. Allopurinol may not be necessary at this time.

• The patient is experiencing a high level of pain due to gout, but the uric acid level is already within a relatively normal range.
• It is recommended to start with a low dose of allopurinol (100 mg daily) and increase as needed, but given the patient's current uric acid level, it may be more appropriate to focus on managing the acute gout attack with other treatments, such as colchicine or anti-inflammatory agents 2.
• The patient should be closely monitored and the treatment plan reassessed periodically to determine the best course of action 2.

From the Research

Gout Treatment and Management

• Gout is a common form of inflammatory arthritis characterized by swelling, pain, or tenderness in a peripheral joint or bursa, including the development of a tophus 3.
• The diagnosis of gout can be made using several validated clinical prediction rules, and arthrocentesis should be performed when suspicion for an underlying septic joint is present 3.

Acute Gout Flare Treatment

• Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes 3, 4.
• The lowest dose of colchicine currently used decreases digestive toxicity, and doses should be adapted to renal function and age, considering possible drug interactions 5.

Urate-Lowering Therapy

• Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 3.
• Allopurinol is an agent of first choice for urate lowering therapy, and the goal is to reduce serum urate levels to below a target of 0.30 mmol/L or 0.36 mmol/L depending on whether it is tophaceous or non-tophaceous respectively 5, 6.
• The daily dose of allopurinol may need to be increased above 300mgs to achieve this objective, but the need to adapt the dose to renal function is a frequent cause of therapeutic failure 5.

Considerations for Allopurinol Treatment

• Screening for HLA*B58:01 mutation is a cost-effective approach to decrease the occurrence of allopurinol hypersensitivity syndrome, especially in Southeast Asian and Black populations 4.
• Febuxostat is another efficacious urate lowering therapy, but it has received a U.S. FDA black box warning for cardiovascular safety 4, 7.
• The median daily dose of allopurinol at both the start and end of treatment is 300 mg, and the dose is rarely increased during followup 7.

Patient Characteristics and Healthcare Utilization

• Patients with gout who are newly prescribed allopurinol, febuxostat, or colchicine have significant comorbidities, including hypertension, hyperlipidemia, diabetes mellitus, and cardiovascular disease 7.
• Febuxostat initiators tend to have more comorbidities and greater health care utilization, including outpatient, inpatient, or emergency room visits, both at baseline and during followup 7.