How to taper Allopurinol (Zyloprim) gradually?

From the Guidelines

To stop allopurinol gradually, it is recommended to reduce the dose by 100mg every 1-2 weeks, under the guidance of a healthcare provider, to prevent triggering gout flares. This approach is based on the understanding that abrupt discontinuation of allopurinol can lead to increased uric acid levels, potentially causing gout attacks 1. For instance, if a patient is taking 300mg of allopurinol daily, the dose could be decreased to 200mg daily for 1-2 weeks, then to 100mg daily for 1-2 weeks before stopping completely.

During this tapering period, prophylactic medications like colchicine or NSAIDs may be recommended to prevent gout attacks, which are common during allopurinol dose changes 1. It is crucial to monitor for signs of gout flares, such as joint pain, redness, or swelling, and to maintain regular follow-up appointments to check uric acid levels. The gradual reduction in allopurinol dose allows the body to adjust to changing uric acid levels, as allopurinol works by inhibiting xanthine oxidase, the enzyme responsible for uric acid production. Sudden withdrawal can cause rapid uric acid level increases, precipitating crystal formation in joints.

Key considerations during the tapering process include:

• Close monitoring of uric acid levels and adjustment of the tapering schedule as needed
• Use of prophylactic medications to prevent gout attacks
• Regular follow-up appointments to assess the patient's condition and adjust the treatment plan accordingly
• Patient education on recognizing signs of gout flares and the importance of adherence to the tapering schedule

By following a gradual tapering schedule and closely monitoring the patient's condition, the risk of gout flares can be minimized, and the patient can safely stop taking allopurinol. This approach is supported by the 2016 updated EULAR evidence-based recommendations for the management of gout, which emphasize the importance of gradual dose reduction and close monitoring during changes in urate-lowering therapy 1.

From the FDA Drug Label

To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (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. In transferring a patient from a uricosuric agent to allopurinol tablets, the dose of the uricosuric agent should be gradually reduced over a period of several weeks and the dose of allopurinol tablets gradually increased to the required dose needed to maintain a normal serum uric acid level.

The process to stop allopurinol gradually is not directly addressed in the provided drug label. However, based on the information about gradually reducing the dose of a uricosuric agent when transferring to allopurinol, it can be inferred that gradual reduction over a period of several weeks may be a reasonable approach to stop allopurinol.

• The label does not provide specific guidance on how to taper allopurinol.
• It is recommended to reduce the dose gradually to minimize potential flare-ups of acute gouty attacks 2.

From the Research

Stopping Allopurinol Gradually

To stop allopurinol gradually, it is essential to consider the following points:

• There are no specific studies that provide a gradual stopping protocol for allopurinol 3, 4, 5, 6, 7.
• However, it is known that allopurinol is typically started at a low dose and gradually increased until the desired therapeutic effect is achieved or the maximum tolerated dose is reached 3, 5.
• When discontinuing allopurinol, it is crucial to monitor the patient's uric acid levels and adjust the dose accordingly to prevent rebound hyperuricemia 4, 6.
• The decision to stop allopurinol should be made under the guidance of a healthcare professional, taking into account the individual patient's condition and medical history 7.

Considerations for Stopping Allopurinol

Some key considerations when stopping allopurinol include:

• The risk of rebound hyperuricemia and potential gout flares 4, 6
• The need for alternative treatments or adjustments to the current treatment regimen 5, 7
• The importance of monitoring uric acid levels and adjusting the treatment plan as needed 3, 6

Alternative Treatments

Alternative treatments for gout, such as febuxostat, may be considered when stopping allopurinol 4, 5, 6.

• Febuxostat has been shown to be effective in reducing uric acid levels and preventing gout flares 4, 5
• However, the choice of alternative treatment should be made under the guidance of a healthcare professional, taking into account the individual patient's condition and medical history 7