For a patient with gout on allopurinol (xanthine oxidase inhibitor) experiencing a flare-up, should they continue allopurinol or switch to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Management of Gout Flare in Patients Already Taking Allopurinol

Continue allopurinol without interruption during the acute gout flare and add appropriate anti-inflammatory therapy (colchicine, NSAIDs, or oral corticosteroids) to treat the flare itself. 1, 2, 3

Critical Management Principle: Two Separate Therapeutic Goals

The key to understanding this scenario is recognizing that allopurinol and NSAIDs serve completely different purposes and are not alternatives to each other 1, 2:

• Allopurinol = long-term urate-lowering therapy (ULT) that prevents future flares by reducing serum uric acid
• NSAIDs/colchicine/corticosteroids = acute anti-inflammatory agents that treat the current flare

Why Continue Allopurinol During the Flare

Stopping allopurinol during an acute flare worsens the flare and complicates long-term management 2, 3. The American College of Rheumatology strongly recommends:

• Continue all urate-lowering therapy without interruption during acute flares 1, 2
• Interrupting ULT causes fluctuations in serum urate levels, which can paradoxically trigger or prolong flares 2
• Maintaining stable urate levels is essential for long-term disease control 1

Treating the Acute Flare: Add Anti-Inflammatory Therapy

The patient needs to ADD (not switch to) one of three first-line anti-inflammatory agents 1, 2:

First-Line Options (Choose One Based on Patient Factors)

1. Oral colchicine (low-dose: 1.2 mg immediately, then 0.6 mg one hour later, maximum 1.8 mg over one hour) 2

   • Most effective when started within 12 hours of symptom onset 2
   • Avoid in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors 2, 3

2. NSAIDs (full FDA-approved anti-inflammatory doses) 1, 2

   • Contraindicated in peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure 2, 3
   • Recent 2025 evidence shows NSAIDs increase cardiovascular risk compared to colchicine (HR 1.56 for MACE, HR 2.50 for cardiovascular death) 4

3. Oral corticosteroids (prednisone 30-35 mg daily for 3-5 days) 2, 3

   • Safest option for patients with renal impairment, cardiovascular disease, or GI contraindications to NSAIDs 2, 3
   • Particularly effective for flares with significant systemic inflammation 2

Treatment Selection Algorithm

Early initiation is the single most critical factor for success, not which agent is chosen 2, 5:

• If renal impairment, heart failure, or cardiovascular disease present → Choose oral corticosteroids 2, 3
• If symptoms <12 hours and no contraindications → Colchicine is preferred 2
• If monoarticular/oligoarticular (1-2 large joints) → Consider intra-articular corticosteroid injection 2, 3
• Avoid NSAIDs given recent cardiovascular safety data showing increased MACE risk 4

Common Pitfalls to Avoid

• Never stop allopurinol during a flare – this is the most critical error that worsens outcomes 2, 3
• Do not delay anti-inflammatory treatment – early initiation within 12 hours dramatically improves success 2, 5
• Do not use NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2, 3
• Do not use full-dose colchicine in severe renal impairment – risk of fatal toxicity 2, 3

Long-Term Prophylaxis Consideration

If this patient is experiencing frequent flares (≥2/year) despite being on allopurinol, this suggests:

• The allopurinol dose may be inadequate – titrate to achieve serum urate <6 mg/dL 1
• Consider adding prophylactic anti-inflammatory therapy (low-dose colchicine 0.5-0.6 mg once or twice daily) for 3-6 months 1, 2
• Verify medication adherence and ensure the treat-to-target strategy is being followed 1