Table 2

Starting preventive therapy for gout with allopurinol: When and how.

WHATWHEN AND HOW
When to startConsider allopurinol if patient has 3 or more gout attacks per year, if unexplained or unavoidable.31,32 Dose range 100–800 mg/d; commonly 300 mg/d
When not to startDo not start allopurinol during an attack of gout; wait 1–2 wk after resolution of the acute episode. Additionally, allopurinol should not be stopped nor should the dose be adjusted during an acute attack of gout, as this can precipitate or worsen symptoms
How to startStart low and go slow

  • Start with 100 mg daily (50 mg daily if estimated GFR ≤ 50 mL/min) and increase every 2–4 wk by 100 mg (or 50 mg if initial dose is 50 mg daily). This will reduce the risk of adverse effects (eg, rash)

  • Protect against allopurinol-induced gout attacks with low-dose colchicine40 (0.6 mg daily or every other day if patient has reduced renal function) or an NSAID (eg, naproxen 375 mg twice daily or ibuprofen 400 mg 3 times daily for 3–6 mo); those with severe gout might benefit from more prolonged prophylaxis. If patient is on ASA for CV risk reduction, naproxen, unlike ibuprofen, does not interact with ASA-platelet adhesion14

How to maintainFor maintenance therapy consider both

  • a target of normal serum uric acid (300–360 μmol/L)31,32, and

  • patient response or tolerance to the drug

Doses exceeding 300 mg daily might be required to reach target serum uric acid in some patients. To improve tolerance divide doses > 300 mg to 2–3 times daily

  • ASA—acetylsalicylic acid, CV—cardiovascular, GFR—glomerular filtration rate.