How to manage an acute gout flare, and is initiation of allopurinol (a xanthine oxidase inhibitor) appropriate?

From the Guidelines

For an acute gout flare, do not start allopurinol immediately, instead focus on reducing inflammation with NSAIDs, colchicine, or corticosteroids, and consider starting allopurinol after the acute flare has resolved, typically 1-2 weeks later, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. When managing an acute gout flare, the primary goal is to reduce inflammation and alleviate symptoms.

• NSAIDs, such as naproxen 500mg twice daily or indomethacin 50mg three times daily, are effective options for reducing inflammation and pain.
• Colchicine, with a loading dose of 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily, is also a recommended treatment for acute gout flares.
• Corticosteroids, such as prednisone 30-40mg daily, tapered over 7-10 days, can be used to reduce inflammation and swelling. In addition to these treatments, it is essential to rest the affected joint, apply ice for 20 minutes several times daily, and stay hydrated. Allopurinol and other urate-lowering therapies should only be initiated after the acute flare has resolved, typically 1-2 weeks later, as starting during a flare can worsen symptoms by mobilizing urate crystals 1. When starting allopurinol, it is recommended to begin at a low dose (100mg daily) and gradually increase while monitoring uric acid levels, aiming for levels below 6mg/dL, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. During the first 3-6 months of allopurinol therapy, use prophylactic low-dose colchicine (0.6mg daily) or an NSAID to prevent flares that commonly occur when uric acid levels are changing, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. It is crucial to note that the choice of treatment should be based on the individual patient's needs and medical history, and that lifestyle modifications, such as weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, can also help to reduce the frequency and severity of gout flares, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained. Accordingly, maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases

Management of Acute Gout Flare:

• Do not start allopurinol for the treatment of an acute gout flare.
• Consider the use of colchicine or anti-inflammatory agents to suppress gouty attacks.
• Allopurinol may be initiated after the acute flare has resolved, with a low dose (100 mg daily) and gradual increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained, but without exceeding the maximal recommended dosage 2, 2.

From the Research

Managing Acute Gout Flare

• The primary goal in managing an acute gout flare is to reduce pain and inflammation, with treatment options including nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and colchicine 3, 4, 5, 6.
• NSAIDs are commonly used to treat acute gout, with low-certainty evidence suggesting they may improve pain at 24 hours and have little to no effect on function, inflammation, or adverse events 4.
• Glucocorticoids are also effective in treating acute gout, with moderate-certainty evidence showing they are probably equally beneficial to NSAIDs in terms of pain relief, improvement in function, and treatment success 4.
• Colchicine is another option for treating acute gout, with evidence demonstrating its effectiveness in reducing pain and inflammation 3, 5, 6.

Starting Allopurinol

• Allopurinol is a urate-lowering therapy (ULT) used to prevent gout flares, but it is not typically started during an acute gout flare 3, 5.
• The treatment of acute gout attacks focuses on NSAIDs, glucocorticoids, and colchicine, while long-term management involves uric acid-lowering treatment with xanthine oxidase inhibitors, such as allopurinol 5.
• It is essential to note that starting allopurinol during an acute gout flare may actually worsen the condition, and it is generally recommended to wait until the acute flare has resolved before initiating ULT 3, 7.
• Flare prevention during the first months of uric acid-lowering treatment is crucial to minimize the risk of further gout attacks, and medications such as colchicine or NSAIDs may be used for this purpose 5, 7.