Should a patient with a history of gout, currently experiencing a flare, continue taking allopurinol (a xanthine oxidase inhibitor) as prescribed?

Should Allopurinol Be Continued During a Gout Flare?

Yes, patients already taking allopurinol should continue it without interruption during an acute gout flare, as stopping worsens the flare and complicates long-term management. 1, 2

Management Algorithm for Patients Already on Allopurinol

Continue Current Allopurinol Dose

• Do not stop or adjust the allopurinol dose during the acute flare - interrupting urate-lowering therapy destabilizes serum urate levels, which can prolong the current flare and trigger additional flares. 1, 2
• The 2020 American College of Rheumatology guidelines strongly recommend against stopping ULT after a flare has begun. 3

Add Anti-Inflammatory Treatment Immediately

• Initiate first-line anti-inflammatory therapy with one of three equally effective options: 1

  • Colchicine: 1.2 mg immediately, followed by 0.6 mg one hour later (most effective within 12 hours of symptom onset) 1
  • NSAIDs: Full FDA-approved anti-inflammatory doses 1
  • Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days 1, 2

• Early treatment initiation is the single most critical factor for success, not which specific agent is chosen. 1

Special Considerations for Treatment Selection

For patients with renal impairment (CKD stage ≥3):

• Oral corticosteroids are the safest first-line option, avoiding nephrotoxicity of NSAIDs and dose-dependent toxicity of colchicine in renal dysfunction. 2
• Avoid NSAIDs in patients with renal impairment, heart failure, uncontrolled hypertension, or active peptic ulcer disease. 2
• Avoid colchicine in severe renal impairment, especially if on strong CYP3A4 or P-glycoprotein inhibitors (risk of fatal toxicity). 1, 2

For monoarticular or oligoarticular flares:

• Intra-articular corticosteroid injection is highly effective and preferred for 1-2 large joints, avoiding systemic exposure. 1, 2

Evidence Supporting Continuation of Allopurinol

Guideline Recommendations

The 2020 ACR guidelines provide clear direction on this issue: 3

• When ULT is indicated during a gout flare, the guidelines conditionally recommend starting ULT during the flare (rather than waiting for resolution)
• By extension, continuing established ULT is even more strongly supported, as stopping creates harmful fluctuations in serum urate

Clinical Trial Evidence

• A 2015 randomized controlled trial demonstrated that initiating allopurinol during acute gout (with appropriate anti-inflammatory coverage) did not prolong the attack compared to placebo (15.4 vs 13.4 days to resolution, p=0.5). 4
• A 2022 randomized controlled trial comparing early versus late allopurinol initiation found no significant difference in time to complete resolution (6 days in both groups, p=0.14). 5
• These studies confirm that allopurinol continuation/initiation during flares is safe when combined with anti-inflammatory therapy. 4, 5

Critical Pitfalls to Avoid

• Never stop allopurinol during a flare - this is the most common error and worsens both acute and long-term outcomes. 1, 2
• Never delay anti-inflammatory treatment - early initiation within 12 hours is crucial for treatment success. 1
• Never use NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease. 1
• Never use full-dose colchicine in severe renal impairment without dramatic dose reduction, especially with concurrent CYP3A4/P-glycoprotein inhibitors. 2, 6

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy. 1, 2
• Ensure adequate fluid intake (≥2 liters daily urinary output) to prevent renal precipitation of urates. 6