Managing Acute Gout Flares When Starting Allopurinol

Prevention of Flares When Starting Allopurinol

• Administering concomitant anti-inflammatory prophylaxis therapy is strongly recommended when initiating allopurinol, according to the American College of Rheumatology, for patients starting allopurinol therapy 1
• Options for prophylaxis include NSAIDs, which can be used to prevent flares in patients starting allopurinol, as recommended by the European League Against Rheumatism 1
• Prophylaxis should be continued for 3-6 months after starting allopurinol, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares, as suggested by the American College of Rheumatology 1

"Start Low, Go Slow" Dosing Strategy

• Begin allopurinol at a low dose of 100 mg daily, and gradually increase the dose by 100 mg increments every 2-4 weeks until reaching the target serum urate level of <6 mg/dL, as recommended by the European League Against Rheumatism 3
• This gradual titration approach reduces the risk of flares associated with treatment initiation, according to the American College of Rheumatology 1

Targeted Prophylaxis Approach

• Anti-inflammatory prophylaxis may be best targeted at patients with higher urate burden, such as those with tophi or frequent attacks, as recommended by the European League Against Rheumatism 1, 3

Special Considerations

• The European League Against Rheumatism notes that starting allopurinol during an acute attack does not significantly prolong the duration of the flare when appropriate anti-inflammatory treatment is provided, but results may not be generalizable to all patients 3, 5