Can allopurinol be started in a patient with acute gout who is already on prednisone (corticosteroid)?

Can Allopurinol Be Started During Acute Gout While on Prednisone?

Yes, allopurinol can be safely started during an acute gout attack in patients already receiving prednisone, provided the patient meets indications for urate-lowering therapy and anti-inflammatory prophylaxis is continued. 1, 2, 3

Key Requirements Before Starting Allopurinol

You must verify the patient meets criteria for urate-lowering therapy, which includes any of the following 2:

• ≥2 gout attacks per year
• Presence of tophi (palpable or visible)
• Chronic gouty arthropathy or radiographic changes
• History of nephrolithiasis
• Urate overproduction

Do not start allopurinol after a first gout attack or in patients with infrequent attacks (<2 per year). 4

Starting Allopurinol During Acute Attack: The Evidence

The 2012 American College of Rheumatology guidelines explicitly state that pharmacologic urate-lowering therapy can be started during an acute gout attack, providing that effective anti-inflammatory management has been instituted. 1 This recommendation is supported by two randomized controlled trials that directly tested this question 5, 6:

• A 2015 RCT showed no prolongation of acute gout when allopurinol was initiated during the attack (15.4 days to resolution with allopurinol vs 13.4 days with placebo, p=0.5) 5
• A 2022 RCT confirmed these findings, showing median time to complete resolution was identical at 6 days in both early and late allopurinol groups (p=0.14) 6

Mandatory Prophylaxis Requirements

You must continue anti-inflammatory prophylaxis when starting allopurinol. Since your patient is already on prednisone for the acute attack, this requirement is met. However, after the acute attack resolves, you need to transition to long-term prophylaxis 1, 2:

First-line prophylaxis options:

• Low-dose colchicine 0.6 mg once or twice daily 1, 2
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI where indicated 1

Second-line option:

• Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated or not tolerated 1

Duration of prophylaxis: Continue for the greater of 1:

• At least 6 months, OR
• 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
• 6 months after achieving target in patients with tophi

Allopurinol Dosing Protocol

Start low and go slow to minimize hypersensitivity risk: 1, 3

1. Initial dose: 100 mg daily (never start higher) 1, 3
2. Titration: Increase by 100 mg every 2-5 weeks 1, 2
3. Target: Serum urate <6 mg/dL (minimum); consider <5 mg/dL if tophi present 1
4. Maximum dose: Can exceed 300 mg/day even with renal impairment, provided adequate monitoring 1

The FDA label specifically warns that "an increase in acute attacks of gout has been reported during the early stages of administration" but notes this has decreased to <1% with current practice of starting at low doses with prophylaxis. 3

Monitoring Requirements

Check serum urate every 2-5 weeks during titration, then every 6 months once at target. 1 This monitoring is particularly important for assessing adherence, which is a common problem in gout management. 1

Watch for hypersensitivity reactions, especially in the first 8 weeks: 3

• Skin rash (most common adverse effect)
• Fever, chills, arthralgias
• Elevated liver enzymes
• Eosinophilia
• DRESS syndrome (drug rash with eosinophilia and systemic symptoms)

Discontinue allopurinol immediately if any rash develops. 3 The risk of severe hypersensitivity is increased with concurrent thiazide use and renal impairment. 1

Critical Pitfalls to Avoid

Do not use the outdated renal-based dosing algorithm that limits allopurinol to 100-300 mg based on creatinine clearance—this approach prevents most patients from reaching target urate levels. 1 Instead, you can titrate above 300 mg/day even with renal impairment, but monitor closely for adverse events. 1

Do not start allopurinol without ensuring prophylaxis is in place. 4, 2 Since your patient is on prednisone for the acute attack, plan the transition to long-term prophylaxis before the prednisone course ends.

Do not stop monitoring after achieving target urate. Continue checking levels every 6 months to ensure adherence and sustained urate control. 1

Special Considerations for Asian Patients

If your patient is of Southeast Asian descent (Han Chinese, Thai, Korean), consider HLA-B*5801 testing before starting allopurinol due to increased risk of severe hypersensitivity reactions in carriers. 1, 4 One recent trial excluded patients with this allele. 6