Should Patients Continue Allopurinol During a Gout Flare?
Yes, patients already taking allopurinol should absolutely continue their current dose without interruption during an acute gout flare. 1, 2, 3
Core Management Principle
Continuing allopurinol during a flare maintains steady urate-lowering effects and prevents serum urate fluctuations that could trigger additional flares. 2 The 2020 American College of Rheumatology guidelines strongly recommend continuing urate-lowering therapy (ULT) to achieve and maintain a serum urate target of <6 mg/dL, regardless of flare status. 1
Treatment Algorithm During an Acute Flare
Step 1: Continue Current Allopurinol Dose
- Never stop or reduce the allopurinol dose that the patient is already taking 2, 3
- Stopping allopurinol leads to serum urate fluctuations that can prolong recovery and trigger subsequent flares 2
Step 2: Treat the Acute Flare Separately
The acute inflammation requires separate therapeutic-dose anti-inflammatory treatment: 2, 3
- Colchicine: 1.2 mg loading dose, then 0.6 mg one hour later (if within 12 hours of flare onset) 2
- NSAIDs: Full anti-inflammatory doses (e.g., naproxen 500 mg twice daily or indomethacin 50 mg three times daily) 2
- Corticosteroids: 30-35 mg prednisolone-equivalent daily for 3-5 days 2
Step 3: Ensure Prophylaxis is in Place
If the patient is not already on prophylaxis, initiate it immediately: 2, 3
- Colchicine 0.5-1 mg daily (preferred) 2
- Low-dose NSAID if colchicine is contraindicated 2
- Low-dose oral corticosteroid as an alternative 2
- Continue prophylaxis for at least 3-6 months 2, 3
Evidence Supporting Continuation
The ACR guidelines conditionally recommend that allopurinol can even be initiated during an acute flare without prolonging flare duration or increasing severity. 1, 2, 3 Two randomized controlled trials demonstrated that starting allopurinol during an acute attack (at 100-300 mg daily) did not prolong pain duration or worsen outcomes compared to delayed initiation. 4, 5, 6 If starting allopurinol is safe during a flare, continuing it is certainly appropriate. 2, 3
Critical Pitfalls to Avoid
- Never discontinue allopurinol during a flare — this creates serum urate fluctuations that can worsen disease control 2
- Do not confuse prophylactic anti-inflammatory therapy with therapeutic treatment — the acute flare requires full therapeutic doses, while prophylaxis uses lower doses to prevent future flares 2
- Never omit prophylaxis — patients on allopurinol without prophylaxis have dramatically higher flare rates in the first 3-6 months 2
- Prophylaxis shorter than 3 months is inadequate — significantly higher flare rates occur when prophylaxis is stopped prematurely 2
Long-Term Management
The ACR strongly recommends continuing ULT indefinitely rather than stopping it, as discontinuation leads to recurrence of flares and disease progression. 1, 3 Maintain serum urate <6 mg/dL lifelong through continued dose titration as needed. 2