SAN ANTONIO — Allopurinol traditionally has not been initiated during an acute gout attack to avoid prolonging the painful arthritis.
Instead, the 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on “consensus opinion of experts, case studies, or standard of care.”
But is avoidance of allopurinol therapy always necessary in that situation? That is what a team of researchers from the San Antonio Military Medical Center, the Alaska VA Healthcare System in Anchorage, the David Grant U.S. Air Force Medical Center in Fairfield, CA and the Uniformed Services University of the Health Sciences in Bethesda, MD, sought to determine.
Results of the study were published in the Journal of Clinical Rheumatolgy.1
Researchers conducted a 28-day, placebo-controlled, double-blind study of allopurinol initiation in patients with acute gout, enrolling patients with crystal-proven gout by arthrocentesis if they presented to the rheumatology clinic with an acute gout attack within 72 hours from initial therapy.
Participants also were required to meet at least one additional criterion for urate-lowering therapy including:
- the presence of gouty tophi,
- more than one acute gout attack per year,
- a history of nephrolithiasis, or
- urate overproduction of more than 1,000 mg in 24-hour urine collection.
Patients were excluded from the study if they had a glomerular filtration rate of less than 50 or liver function test of greater than 1.25 times the upper limit of normal.
With the treating physician determining therapy for the acute gout attack, standard prophylaxis, with colchicine or nonsteroidal anti-inflammatory drugs, was prescribed. Allopurinol or placebo was initiated at 100 mg daily for the first 14 days, then increased to 200 mg daily for the next 14 days.
The primary endpoint was protocol defined days to resolution of acute gout, incorporating patient-rated joint pain and physician examination. Secondary measures included Physician Global Assessment, patient-rated pain, adverse effects of therapy and serum uric acid.
Results indicate that 31 patients — 17 on placebo and 14 on allopurinol) — completed the study. Both intent to treat and completer analyses showed only a statistically insignificant difference in days to — 15.4 days in the allopurinol group completers vs. 13.4 days in the placebo group. The acute phase of pain rapidly improved in both groups, according to the report.
“We initiated allopurinol at low doses during an acute gout attack in patients who met criteria for starting urate-lowering therapy and did not have abnormal kidney or liver function,” the study authors concluded. “In this cohort, allopurinol did not prolong the acute, treated attack.”
1 Hill EM, Sky K, Sit M, Collamer A, Higgs J. Does starting allopurinol prolong acute treated gout? A randomized clinical trial. J Clin Rheumatol. 2015 Apr;21(3):120-5. doi: 10.1097/RHU.0000000000000235. PubMed PMID: 25807090.