Discontinuation of Allopurinol
Allopurinol should be continued indefinitely rather than discontinued, even in patients who achieve clinical remission with no gout flares for ≥1 year and no tophi. 1
Evidence Against Discontinuation
The 2020 American College of Rheumatology guidelines conditionally recommend continuing urate-lowering therapy (ULT) indefinitely over stopping it, though this recommendation is based on very low-quality evidence. 1
Key Data on Relapse After Discontinuation
In a case series of patients in clinical remission who stopped ULT after years of well-controlled serum urate (SU) levels, only 13% (27 of 211 patients) remained flare-free during 5-year follow-up when their SU stayed <7 mg/dL off therapy. 1
Patients with higher SU concentrations after withholding therapy experienced more frequent flares, with a direct correlation between higher SU levels and increased likelihood of flares. 1
A systematic review found relapse rates of 36-81% in gout patients after ULT discontinuation, with relapses typically occurring 1-4.5 years after stopping therapy. 2
Relapse rates were lower (15%) in patients with urolithiasis compared to those with gouty arthritis. 2
When Discontinuation Might Be Considered
If discontinuation is being contemplated despite guideline recommendations, the following factors suggest lower relapse risk:
Low serum urate levels both before and after ULT discontinuation are associated with reduced gout recurrence. 2
Patients must be in clinical remission: no flares for ≥1 year and complete resolution of tophi. 1
Patient Perspective
Patient panels consistently express concerns about return or worsening of gout symptoms, tophi, or joint damage with ULT cessation. If therapy is well-tolerated and not burdensome, patients prefer to continue treatment. 1
FDA Labeling Guidance
The FDA label states that "treatment with allopurinol tablets should be discontinued when the potential for overproduction of uric acid is no longer present," specifically referencing patients with leukemia, lymphoma, or malignancies receiving cancer therapy. 3 This does not apply to chronic gout management, where urate overproduction or underexcretion persists lifelong.
Clinical Approach
The treat-to-target strategy requires maintaining serum urate <6 mg/dL indefinitely to prevent crystal formation and disease recurrence. 1, 4 Discontinuation undermines this fundamental therapeutic principle, as the underlying metabolic abnormality causing hyperuricemia does not resolve.
Common Pitfall
Do not discontinue allopurinol simply because a patient has been symptom-free for an extended period—this reflects successful disease control, not disease resolution. 1