What is the recommended management for a 65‑year‑old woman with gout who discontinued allopurinol several months ago and now has a serum uric acid of 7.4 mg/dL?

Recommendation for Restarting Allopurinol in a 65-Year-Old Woman with Gout

Restart allopurinol immediately at a low dose of 100 mg daily, titrate upward by 100 mg every 2–4 weeks until serum uric acid falls below 6 mg/dL, and provide mandatory flare prophylaxis with colchicine, NSAIDs, or low-dose prednisone for at least 3–6 months. 1, 2

Rationale for Restarting Urate-Lowering Therapy

Your patient has a history of gout and a current serum uric acid of 7.4 mg/dL, which exceeds the therapeutic target of <6 mg/dL (360 μmol/L). 1 This level promotes continued monosodium urate crystal formation and puts her at risk for recurrent flares, progressive joint damage, and tophus formation. 1

Allopurinol remains the first-line urate-lowering therapy for all patients with gout, including those with moderate-to-severe chronic kidney disease. 1 The 2020 American College of Rheumatology guidelines strongly recommend allopurinol over alternatives due to its efficacy, safety profile, tolerability, and lower cost. 1

Starting Dose and Titration Protocol

Initial Dosing

• Start allopurinol at 100 mg once daily if renal function is normal (CrCl >60 mL/min). 1, 2, 3
• If she has stage 4 or worse CKD (CrCl <30 mL/min), start at 50 mg daily. 1, 2
• The low starting dose minimizes the risk of allopurinol hypersensitivity syndrome and reduces early gout flares during initiation. 2, 3

Dose Escalation

• Increase the dose by 100 mg every 2–4 weeks based on serum uric acid monitoring until the target of <6 mg/dL is achieved. 1, 2, 3
• Check serum uric acid every 2–4 weeks during active titration to implement the treat-to-target strategy. 1, 4
• Do not stop at 300 mg daily—more than 50% of patients fail to reach target uric acid levels at ≤300 mg daily, and doses up to 800 mg daily are FDA-approved and often necessary. 1, 2, 3
• Each 100 mg increment of allopurinol lowers serum uric acid by approximately 1 mg/dL (60 μmol/L). 1, 2

Mandatory Flare Prophylaxis

Initiate anti-inflammatory prophylaxis immediately when starting or titrating allopurinol to prevent paradoxical gout flares. 1, 2 Rapid reduction in serum uric acid mobilizes urate crystals from tissue deposits, triggering acute attacks. 2

Prophylaxis Options

• Colchicine 0.5–1.2 mg daily (most commonly used). 1, 2
• Low-dose NSAIDs with gastroprotection if no contraindications. 1
• Prednisone/prednisolone 5–10 mg daily if colchicine and NSAIDs are contraindicated. 1, 2

Duration

• Continue prophylaxis for at least 3–6 months after allopurinol initiation. 1, 2
• Extend prophylaxis duration if flares persist during dose escalation. 1, 2
• Monitor for flare activity at each visit and adjust prophylaxis accordingly. 1

Therapeutic Target and Monitoring

Target Serum Uric Acid

• Maintain serum uric acid <6 mg/dL (360 μmol/L) for all gout patients to prevent crystal formation and promote crystal dissolution. 1, 5
• If she has severe gout (tophi, chronic arthropathy, or frequent attacks), target a lower level of <5 mg/dL (300 μmol/L) until complete crystal dissolution occurs. 1, 4, 5

Follow-Up Schedule

• Check serum uric acid every 2–4 weeks during dose titration until target is achieved. 1, 4
• Once stable at target, monitor serum uric acid every 6 months. 4, 5
• Assess renal function every 6 months, as allopurinol dosing may require adjustment if kidney function changes. 1, 5

Special Considerations

Renal Function

• Assess renal function before initiating allopurinol. 1
• Modern guidelines support dose titration above 300 mg even in moderate-to-severe CKD (stage ≥3) with careful monitoring, rejecting outdated renal-based dosing caps. 1, 2
• For CKD stage 3 (CrCl 30–59 mL/min), start at 50–100 mg daily and titrate gradually. 2

Cardiovascular Risk Factors

• Assess cardiovascular risk factors, as hyperuricemia is associated with hypertension, diabetes, chronic kidney disease, and heart failure. 1, 6

Timing of Initiation

• You can start allopurinol even during an active gout flare if appropriate anti-inflammatory prophylaxis is provided; waiting for flare resolution is unnecessary. 1, 2, 7
• Starting during a flare does not prolong flare duration or severity when adequate anti-inflammatory therapy is given. 7

Lifelong Therapy

Emphasize that allopurinol is lifelong therapy. 4, 5 Discontinuation leads to recurrence of gout flares in approximately 87% of patients within 5 years. 4, 5 Once the target serum uric acid is achieved and maintained, continue the effective dose indefinitely. 5, 3

Critical Pitfalls to Avoid

• Do not use a fixed 300 mg daily dose without titration—this fails to achieve target serum uric acid in >50% of patients and represents suboptimal care. 1, 2
• Do not start allopurinol without concurrent flare prophylaxis—this significantly increases the risk of acute gout flares and reduces treatment adherence. 1, 2
• Do not discontinue allopurinol after achieving symptom control—this leads to recurrence of gout flares in the vast majority of patients. 4, 5
• Do not rely on outdated renal dosing algorithms that cap allopurinol at 300 mg in CKD—these are non-evidence-based and impede adequate urate control. 1, 2