Should allopurinol (Nonsteroidal Anti-Gout medication) be taken during an acute gout attack?

Should You Take Allopurinol During an Acute Gout Attack?

You can safely start allopurinol during an acute gout attack as long as you are simultaneously treating the acute inflammation with NSAIDs, colchicine, or corticosteroids. 1, 2, 3

Evidence Supporting Initiation During Acute Attacks

The traditional teaching to delay allopurinol initiation until 2 weeks after flare resolution has been challenged by recent evidence:

• Two randomized controlled trials demonstrate that starting allopurinol during an acute attack does not prolong pain or worsen outcomes when patients receive concurrent anti-inflammatory therapy 2, 3

• In one trial of 57 patients, allopurinol 300 mg daily started during acute gout showed no significant difference in days to resolution (15.4 days with allopurinol vs 13.4 days with placebo, p=0.5) 2

• A second trial of 51 patients found no difference in daily pain scores between groups starting allopurinol versus placebo during acute attacks, with both groups showing similar pain reduction from baseline to day 10 3

• EULAR guidelines now suggest that starting allopurinol during an acute attack may be safe if anti-inflammatory therapy is provided concurrently 1

Critical Requirements When Starting During Acute Attack

You must follow this approach to safely initiate allopurinol during an acute flare:

• Always treat the acute inflammation first with NSAIDs, colchicine, or corticosteroids - these address the inflammatory process causing pain and swelling 1, 4

• Start allopurinol at a low dose (100 mg daily) and increase by 100 mg every 2-4 weeks as needed to reach target serum uric acid <360 μmol/L (6 mg/dL) 4

• Provide mandatory anti-inflammatory prophylaxis with low-dose colchicine (0.5-1 mg daily) or NSAIDs for at least 6 months when initiating urate-lowering therapy to prevent recurrent flares 4, 1, 4

When Allopurinol Is Actually Indicated

Allopurinol is for long-term prevention, not acute treatment. Start it only if the patient meets criteria for urate-lowering therapy:

• Recurrent acute attacks (≥2 per year) 4
• Presence of tophi 4
• Chronic gouty arthropathy or radiographic changes 4
• History of nephrolithiasis 2
• Chronic kidney disease 4

Do not initiate long-term urate-lowering therapy after a first gout attack or in patients with infrequent attacks (<2 per year) 4

Important Caveats and Safety Considerations

• In Asian patients (Han Chinese, Thai, Korean) with CKD stage ≥3, test for HLA-B*5801 before starting allopurinol due to increased risk of fatal hypersensitivity reactions 1

• Adjust dose in renal impairment - allopurinol requires dose reduction with declining kidney function 4

• Urate-lowering therapy reduces gout flares after 1 year but not within the first 6 months - this is why prophylaxis is essential 4

• Stop diuretics if possible when gout is associated with diuretic use, as they raise uric acid levels 4

Practical Algorithm

For a patient presenting with acute gout:

1. Treat the acute flare immediately with NSAIDs (first-line), colchicine (low-dose: 1.2 mg followed by 0.6 mg 1 hour later), or corticosteroids 4

2. Assess if patient meets criteria for long-term urate-lowering therapy (recurrent attacks, tophi, arthropathy, radiographic changes) 4

3. If criteria met, you can start allopurinol 100 mg daily during the acute attack while continuing anti-inflammatory treatment 1, 2, 3

4. Initiate prophylaxis with colchicine 0.5-1 mg daily or NSAID (with gastroprotection if indicated) for at least 6 months 4, 1

5. Titrate allopurinol by 100 mg every 2-4 weeks until serum uric acid <360 μmol/L 4