From the Guidelines
Starting allopurinol during an acute flare of gout is conditionally recommended, provided that concomitant anti-inflammatory prophylaxis therapy is initiated simultaneously. This approach is supported by the 2020 American College of Rheumatology guideline for the management of gout 1. When initiating allopurinol during a gout flare, it is crucial to start at a low dose, typically less than 100 mg/day, and especially lower in patients with chronic kidney disease (CKD), with subsequent dose titration to target serum uric acid levels below 6 mg/dL.
Key considerations for managing gout include:
- Initiating concomitant anti-inflammatory prophylaxis therapy, such as colchicine, NSAIDs, or prednisone/prednisolone, to prevent worsening of the flare due to rapid changes in uric acid levels 1.
- Continuing prophylaxis for 3–6 months rather than less than 3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares 1.
- Choosing the specific anti-inflammatory prophylaxis based on patient factors, such as renal function, comorbidities, and potential drug interactions.
The traditional approach of waiting until the acute attack has resolved before initiating allopurinol is still valid, especially if there are concerns about exacerbating the flare. However, with appropriate prophylaxis and careful dose titration, starting allopurinol during an acute flare can be a viable option, as suggested by recent guidelines 1.
From the FDA Drug Label
The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases 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. Past experience suggested that the most frequent event following the initiation of allopurinol treatment was an increase in acute attacks of gout (average 6% in early studies).
Starting allopurinol during an acute flare of gout is not recommended. It is advised to start with a low dose of allopurinol (100 mg daily) and 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. Colchicine or anti-inflammatory agents may be required to suppress gouty attacks during the initiation of allopurinol therapy 2.
From the Research
Allopurinol Initiation During Acute Gout Flare
- The traditional approach has been to avoid initiating allopurinol during an acute gout attack to prevent prolonging the painful arthritis 3.
- However, the 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on expert opinion 3.
- A randomized clinical trial found that initiating allopurinol at low doses during an acute gout attack did not prolong the acute, treated attack 3.
- Another study found that colchicine prophylaxis during initiation of allopurinol for chronic gouty arthritis reduces the frequency and severity of acute flares 4.
Comparison of Allopurinol and Febuxostat
- A post-hoc analysis of a randomized multicenter trial found that the risk of gout flares during the initiation and escalation of allopurinol and febuxostat is similar when these agents are administered according to a treat-to-target strategy 5.
- The study found that factors independently associated with flare risk during ULT initiation/escalation included younger age, higher baseline serum uric acid, and absence of tophi 5.
Early vs Late Allopurinol Initiation
- A randomized controlled trial found that early allopurinol initiation during an acute gout flare did not lead to significant changes in time to resolution, flare recurrence, and inflammatory markers compared to late initiation 6.
- The study suggests that allopurinol can be initiated early in the course of an acute gout flare without worsening the outcome 6.