The recommendation to not stop allopurinol during a gout attack is very good advice. Unfortunately, it leads to a basic misunderstanding in some people.
In this article, I look at this misunderstanding, and how we can now easily avoid it. Before that, let me explain what used to be the standard advice for allopurinol dosing.
For many decades, the standard advice to gout patients who are about to start allopurinol was:
- Wait until acute gout attack has gone before starting allopurinol
- Once started, never stop allopurinol if you get a gout attack
The second part of the advice was always very good and remains so today. Once you start allopurinol, you should only stop if you feel it is causing the serious side-effects that are listed on the product label. Such side-effects are rare, and you should discuss them immediately with your doctor. Assuming that you are one of the large majority who tolerates allopurinol safely, there are very good reasons why you should never stop it. There is also one special situation where you can stop allopurinol, at least for a while.
Allopurinol puts gout under control. After a few months, if it is prescribed properly, it will cause enough uric acid crystal deposits to dissolve so that you will never suffer another gout attack. Until most of your uric acid crystals have dissolved, you are at risk from a gout attack. If you stop taking allopurinol at this stage, you will extend the length of time you risk gout attacks. For this reason, you should not stop taking allopurinol if you have a gout attack. Stopping allopurinol will not change that attack, but it will put you at risk of more attacks than you would otherwise suffer.
Once you have cleared most uric acid deposits from your body, you might be eligible for an allopurinol vacation. The difficulty here is knowing when old deposits have been cleared. If you have visible tophi, then you still have uric acid deposits. If you have not had a gout flare for over six months, and your uric acid level has remained ay 5mg/dL, or below, throughout that time, then you probably do not have significant uric acid deposits.
If you and your doctor are confident that most uric acid deposits have dissolved, then you might take a break from allopurinol. In this case, you must arrange for blood tests to continue to monitor your uric acid levels. There are no hard and fast rules for how frequently you get the blood test, so your doctor should be able to advise you. 3 to 6 months seems sensible to me. If uric acid rises above 6, then you should restart allopurinol.
Never Delay Allopurinol For Gout Attacks
Now we go back to the old advice of not starting allopurinol during a gout attack. There was never a consensus for this advice, but many doctors believed it to be the best way to start allopurinol dosing. As I reported last year, there is new evidence to show that you should never delay starting allopurinol.
I can see from recent gout forum discussions that the message has not been universally acknowledged. It is time to change that attitude by keeping the advice simple:
Never delay starting allopurinol, and once you start it, never stop.
Leave Do Not Stop Allopurinol During A Gout Attack to browse the Allopurinol Dosing Guidelines.