Can You Take Allopurinol During a Gout Attack?
Yes, allopurinol can be started during an acute gout attack, provided effective anti-inflammatory treatment is established simultaneously. 1
Evidence-Based Recommendation
The American College of Rheumatology supports initiating urate-lowering therapy during an acute gout attack when appropriate anti-inflammatory treatment is in place (strength of evidence C). 1 This represents a shift from traditional practice, which historically avoided starting allopurinol during acute flares.
Critical Requirements Before Starting
You must establish effective anti-inflammatory therapy first, which includes: 1
- NSAIDs (such as indomethacin 50 mg three times daily) 2
- Colchicine (low-dose: 1.2 mg followed by 0.6 mg 1 hour later for acute treatment) 3
- Corticosteroids as an alternative 1
Prophylactic colchicine 0.5-1 mg/day must be started simultaneously and continued for at least 6 months. 1 This is non-negotiable, as the FDA label explicitly warns that "an increase in acute attacks of gout has been reported during the early stages of administration" and "maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun." 4
Dosing Strategy: Start Low, Go Slow
Begin allopurinol at 100 mg daily maximum during the acute attack. 1, 4 The FDA label specifically recommends starting with 100 mg daily and increasing at weekly intervals by 100 mg until serum uric acid reaches ≤6 mg/dL, without exceeding 800 mg per day. 4
After the initial period, titrate slowly every 2-5 weeks (some sources suggest 2-4 weeks) until target uric acid <6 mg/dL is achieved. 1, 5
Clinical Trial Evidence
Three randomized controlled trials directly addressed this question:
2012 study (n=51): Allopurinol 300 mg initiated during acute attack showed no significant difference in daily pain scores (VAS 6.72 vs 6.28 at baseline, declining to 0.18 vs 0.27 at day 10, p=0.54) or subsequent flares (2 vs 3 patients, p=0.60) compared to placebo. 2
2015 study (n=31): Days to resolution were not significantly different (15.4 days with allopurinol vs 13.4 days with placebo, p=0.5). 6
2022 study (n=115): Median time to complete resolution was identical between early and late initiation groups (6 days in both, p=0.14). 7
These trials consistently demonstrate that starting allopurinol during an acute attack does not prolong the flare when appropriate anti-inflammatory therapy is provided. 6, 2, 7
Important Caveats
EULAR guidelines note that study populations were limited and results with allopurinol 200-300 mg may not generalize to more potent urate-lowering medications like febuxostat or combination therapies. 1 The trials also excluded patients with advanced renal failure (GFR <50) and abnormal liver function. 6
Common Pitfalls to Avoid
Starting without prophylaxis: This dramatically increases the risk of triggering additional attacks. Without colchicine prophylaxis, 77% of patients experienced gout attacks versus 33% with prophylaxis. 3, 8
Using too high a starting dose: Doses >100 mg increase the risk of triggering attacks and hypersensitivity reactions, including potentially fatal DRESS syndrome. 1, 4
Stopping prophylaxis too early: Discontinuing prophylaxis at 8 weeks caused a spike in acute attacks (doubling from 20% to 40%), while continuing for 6 months prevented this spike. 3, 1
Stopping titration at 300 mg: More than half of patients do not reach target uric acid levels with ≤300 mg allopurinol. 1 Continue titrating as needed, as doses up to 600 mg/day are well tolerated in patients with preserved renal function and achieve therapeutic goals in 92.5% of patients. 9
Special Populations
In patients with decreased renal function, lower doses are required. The FDA label states that patients with severely impaired renal function may only need 100 mg per day or 300 mg twice weekly due to prolonged half-life of oxipurinol. 4 Carefully observe these patients during early therapy stages. 4