Should You Start Allopurinol?
Yes, you should start allopurinol. With 2 gout attacks in the past year (≥2 flares per year) and a serum uric acid of 360 μmol/L (6.1 mg/dL), you meet strong indications for urate-lowering therapy according to both the American College of Rheumatology and European League Against Rheumatism guidelines 1, 2.
Why You Need Allopurinol
Your clinical picture warrants immediate treatment:
- Frequent gout flares (≥2 per year) are a strong indication for starting urate-lowering therapy, regardless of your current serum uric acid level 1, 2
- The American College of Rheumatology strongly recommends (not conditionally) initiating allopurinol for patients with frequent gout flares defined as >2 per year 1, 2
- Your serum uric acid of 360 μmol/L (6.1 mg/dL) is already close to the therapeutic target of <360 μmol/L (<6 mg/dL), but without treatment, you will continue having recurrent attacks 1
How to Start Allopurinol Properly
Initial Dosing Strategy
Start low and go slow to minimize flare risk during initiation:
- Begin with 100 mg daily (or 50 mg daily if you have chronic kidney disease stage ≥4) 1, 2, 3
- Increase by 100 mg every 2-4 weeks based on serum uric acid monitoring 1, 2, 3
- Your target is serum uric acid <360 μmol/L (<6 mg/dL) for maintenance 1, 2
- Most patients require 300-600 mg daily to reach target, with maximum dose up to 800 mg daily if needed 3, 4
Mandatory Flare Prophylaxis
You must take anti-inflammatory prophylaxis when starting allopurinol to prevent paradoxical gout flares:
- Colchicine 0.5-1 mg daily is the preferred prophylactic agent for 3-6 months after starting allopurinol 1, 2, 5
- Alternative options include low-dose NSAIDs or low-dose corticosteroids if colchicine is contraindicated 2
- This prophylaxis is separate from treating any acute flare you might experience 2
Monitoring Schedule
- Check serum uric acid every 2-5 weeks during dose titration 2, 3
- Once target is reached, monitor every 3-6 months 6
- Continue allopurinol lifelong once started—this is not a short-term medication 1, 6
Common Pitfalls to Avoid
Do not start at 300 mg daily without titration—this "standard dose" is actually inadequate for most patients and increases flare risk 2, 7. The FDA label explicitly recommends starting at 100 mg daily and increasing gradually 3.
Do not stop allopurinol if you have a gout flare after starting it—continue the medication and treat the acute flare separately with anti-inflammatory therapy 2, 8. Stopping and starting allopurinol causes serum uric acid fluctuations that trigger more flares 2.
Do not skip the prophylactic anti-inflammatory medication—starting allopurinol without prophylaxis significantly increases your risk of gout flares during the first 3-6 months 2, 5.
Why This Matters for Your Long-Term Health
Without treatment, recurrent gout attacks lead to:
- Progressive joint damage and chronic arthropathy 1, 3
- Development of tophi (urate crystal deposits) 1, 3
- Potential kidney damage from urate nephropathy 3, 5
- Increased frequency and severity of future attacks 1
Allopurinol is the first-line, gold-standard treatment for gout with excellent long-term safety and efficacy when dosed appropriately 1, 2. Starting now, before you develop complications, offers the best outcomes for preventing joint damage and maintaining quality of life 1, 2.