Allopurinol Management During Gout Flares

Introduction to Gout Management

The American College of Rheumatology (ACR) guidelines conditionally recommend starting urate-lowering therapy (ULT) during a gout flare rather than waiting until the flare has resolved, based on moderate certainty of evidence 1
The ACR guidelines indicate that allopurinol can be initiated during a flare, and by extension, it should be continued if already started 3

The American College of Rheumatology recommends continuing existing allopurinol dose without interruption during a gout flare 1
The American College of Rheumatology suggests treating the acute flare with appropriate anti-inflammatory therapy, such as colchicine, NSAIDs, or corticosteroids based on patient factors 4
The choice of anti-inflammatory agent should be individualized based on comorbidities and contraindications, as recommended by the American College of Rheumatology 5

The American College of Rheumatology recommends maintaining the current dose of allopurinol if the patient is already on it 6
The American College of Rheumatology suggests starting allopurinol at a low dose (≤100 mg/day, lower in patients with CKD) if initiating during a flare 1
The American College of Rheumatology recommends continuing the treat-to-target strategy with gradual dose titration to achieve serum urate <6 mg/dL 7

The American College of Rheumatology strongly recommends anti-inflammatory prophylaxis for patients starting or continuing allopurinol 4
The American College of Rheumatology suggests continuing prophylaxis for 3-6 months with ongoing evaluation 5
The American College of Rheumatology recommends continuing ULT indefinitely rather than stopping it, as discontinuation often leads to recurrence of flares 6