What are the treatment options for acute gouty arthritis in my left foot, characterized by severe pain, rated 8 out of 10, and potential consideration for Allopurinol (Zyloprim)?

From the Guidelines

I strongly recommend that you seek immediate medical attention for your severe gout attack, and your doctor may prescribe anti-inflammatory medications like colchicine, NSAIDs, or corticosteroids for immediate relief, rather than starting allopurinol during the acute phase. According to the 2020 American College of Rheumatology guideline for the management of gout 1, allopurinol is not recommended for treating acute gout attacks and can actually worsen symptoms if started during a flare-up.

For immediate relief, your doctor may prescribe anti-inflammatory medications like colchicine, NSAIDs (such as naproxen or indomethacin), or corticosteroids, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. In the meantime, rest your foot, apply ice for 20-30 minutes several times daily, elevate your foot when possible, and drink plenty of water.

Once your acute attack resolves, your doctor can discuss starting allopurinol (typically at 100mg daily, gradually increasing if needed) for long-term prevention, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Allopurinol works by reducing uric acid production, preventing crystal formation in joints that causes gout attacks. However, it requires regular monitoring of uric acid levels and kidney function, and must be taken consistently to be effective.

Some key points to consider:

• The 2020 American College of Rheumatology guideline for the management of gout 1 recommends a treat-to-target management strategy with ULT dose titration guided by serial serum urate measurements, with an SU target of <6 mg/dl.
• When initiating ULT, concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months was strongly recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
• Dietary changes like limiting alcohol, red meat, and seafood may also help manage your condition, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

From the FDA Drug Label

Allopurinol tablets are indicated in: 1. the management of patients with signs and symptoms of primary or secondary gout (acute attacks, tophi, joint destruction, uric acid lithiasis, and/or nephropathy). The FDA drug label supports the use of allopurinol for gout.

• Gout treatment: Allopurinol can be used to manage patients with signs and symptoms of primary or secondary gout, including acute attacks.
• Dosage: The dosage of allopurinol to accomplish full control of gout varies with the severity of the disease, with an average of 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout 2. It is recommended to start with a low dose of allopurinol (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, without exceeding the maximal recommended dosage of 800 mg daily 2, 2. Key considerations:
• The patient should be aware that an increase in acute attacks of gout has been reported during the early stages of administration of allopurinol, even when normal or subnormal serum uric acid levels have been attained 2.
• Maintenance doses of colchicine may be given prophylactically when allopurinol is begun, and the use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases 2.

From the Research

Gout Management and Treatment

• Gout is an inflammatory arthritis that typically presents as acute onset, recurrent, monoarticular pain 3.
• The management of pain, risk assessment for future flares, and disability is not optimal in most patients, and diagnostic and management approaches are applied inconsistently 3.
• Therapeutic options for treating acute gout flares include colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids 3, 4, 5.

Allopurinol for Gout Treatment

• Allopurinol is a urate-lowering therapy that can be used to prevent gout flares 3, 4, 6.
• It is typically initiated after the acute flare has resolved, and prophylaxis with a flare prevention medication, such as colchicine, is administered to prevent future flares 3.
• Allopurinol is an agent of first choice for urate lowering therapy, but screening for HLA*B58:01 mutation is recommended in certain populations to decrease the occurrence of allopurinol hypersensitivity syndrome 6.

Indications for Allopurinol

• Indications for long-term urate-lowering therapy, such as allopurinol, include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 4.
• Patient education, especially counseling on risk factors and contributors to hyperuricemia and gout, can improve the likelihood of successful therapy for this often suboptimally managed disease 3.

Treatment of Acute Gout

• Acute gout is traditionally treated with NSAIDs, corticosteroids, and colchicine, but novel therapies, such as IL-1β antagonists, are also effective for arresting flares 5, 6.
• Lifestyle modifications, such as diet and exercise, can also play a role in preventing gout flares 4, 7.
• Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy to prevent acute gouty arthritis for a period of at least 6 months 7.