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 For Life
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.
How Long should you take Allopurinol?
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.
Do you have to take Allopurinol For Life?
Subsequently, that idea of intermittent allopurinol treatment has been considered in several other gout reviews and treatment guidelines. Including:
- Philippine Gout Management Guidelines 
- Here the committee found strong evidence to recommend continuous allopurinol treatment over intermittent treatment.
- Allopurinol Duration Is A Key Clinical Question 
- Stamp considers that the lifetime vs intermittent allopurinol is one of the major unanswered questions in gout management:
Another key clinical question is how long ‘target’ urate should be maintained.
However, there is an implication that allopurinol should be a life-long treatment. Because even if gout patients take a break from allopurinol, gout will return – “suggesting that life-long therapy is required to prevent recurrence.”
Elsewhere, Perez-Ruiz developed the intermittent treatment approach. With the idea of a two-stage approach to allopurinol treatment. Subsequently, patients and rheumatologists updated the 2020 ACR gout management guidelines. To recommend that allopurinol should continue indefinitely in most cases. Allowing for intermittent treatment where doctor and patient agree together to change allopurinol lifetime dosage.
The Patient Panel voiced concerns about a return or worsening of gout symptoms, tophi, or joint damage with ULT cessation. If therapy is well-tolerated and not burdensome, the Patient Panel expressed a preference to continue treatment.
Do I have to take Allopurinol Forever?
As you can see, the “default setting” is to take allopurinol forever. But the latest recommendation is that this is something that needs to be decided jointly between doctor and patient. So discuss your allopurinol duration with your doctor first. Then, if required, you can create a plan for reducing or stopping allopurinol.
Leave Allopurinol Lifetime Dosage to read the allopurinol pages.
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.
- Li-Yu, J., E. O. Salido, S. Manahan, J. J. Lichauco, J. P. Lorenzo, K. T. Torralba, A. A. Raso, L. C. Roberto, P. Santos Estrella, and L. M. Maceda. “Philippine Clinical Practice Guidelines for the Management of Gout Technical Review Committee Members.”
- Stamp, Lisa K. “Major unanswered questions in the clinical gout field.” Current opinion in rheumatology 29, no. 2 (2017): 171-177.
- Perez-Ruiz, Fernando, Ana Maria Herrero-Beites, and Loreto Carmona. “A two-stage approach to the treatment of hyperuricemia in gout: The “dirty dish” hypothesis.” Arthritis & Rheumatism 63, no. 12 (2011): 4002-4006.
- FitzGerald, John D., Nicola Dalbeth, Ted Mikuls, Romina Brignardello-Petersen, Gordon Guyatt, Aryeh M. Abeles, Allan C. Gelber et al. “2020 American College of Rheumatology Guideline for the Management of Gout.” Arthritis Care & Research (2020).
Allopurinol Lifetime Dosage Document Change History
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