The biggest question for gout patients contemplating, or just starting on, allopurinol is “Do I have to take allopurinol for the rest of my life?”
Like most gout questions, there is no certain answer. The lazy response is “Yes, allopurinol is a lifetime drug.”
But why is this lazy?
Allopurinol is taken for one reason alone – to lower uric acid if it rises above your safe level. Safe uric acid levels need to be set on an individual basis, but for most gout patients it is 5 mg/dL (0.30 mmol/L). However, allopurinol is often mismanaged, and prescribed without reference to frequent uric acid test results. Unlike many medicines that can be prescribed with a standard dosage, allopurinol must be matched to the individual, and the only way to do that is by frequent uric acid testing. In fact, this applies to all Urate Lowering Treatments/Therapies (ULT), since their purpose is uric acid control, with gout control being the outcome only when ULT is managed correctly and safe uric acid levels are achieved.
Leaving aside any form of gout treatment for the moment, all gout sufferers must accept that they need to know their uric acid number, and they must be tested at least once a year. Usually, this is simply part of an annual health check.
So, if we change the original question to “Is uric acid testing a lifetime requirement?” the answer is always “Yes” for gout patients.
And the requirement for allopurinol simply depends on the results of those tests.
For many gout patients, once uric acid has risen to the point that it causes gout, then it never falls back to safe levels without the intervention of allopurinol, or other uric acid lowering gout medications. But high uric acid has many causes. Some of these causes are reversible, and removing the cause may mean that patients can reduce the allopurinol dose, or even stop all together.
This can only be judged from uric acid test results. Even if allopurinol is deemed to be unnecessary, you should still be tested every year to ensure that uric acid never rises to levels that put you at risk of future gout attacks.
The view that allopurinol might be an intermittent treatment, rather than a lifetime commitment, is upheld by Perez-Ruiz and colleagues:
Proper and long-term reduction of serum urate level is associated with long-term periods in which patients are free of gouty symptoms, probably due to the reduction of the urate pool. These results suggest that 5-year intermittent, instead of life-long, ULT could be offered to patients with good serum urate control during ULT.
Allopurinol Lifetime Dosage References
- Using serum urate levels to determine the period free of gouty symptoms after withdrawal of long-term urate-lowering therapy: a prospective study. Perez-Ruiz F, Atxotegi J, Hernando I, Calabozo M, Nolla JM. Arthritis Rheum. 2006 Oct 15;55(5):786-90.