My allopurinol dosing guidelines describe the correct way to start and stop taking allopurinol. In essence, you should start taking allopurinol as soon as gout is diagnosed. In most cases, you will continue to take it for the rest of your life, but see the guidance on “allopurinol vacations” below.
Allopurinol Dosing Preparation
Recent gout research has identified certain genetic profiles that indicate a high risk of Allopurinol Hypersensitivity Syndrome (AHS). If you fall into the high-risk ethnic groups, your doctor should arrange genetic screening tests prior to choosing allopurinol as your uric acid lowering medication. Please see Minimize Allopurinol Side Effects for more information.
Whichever uric acid lowering treatment applies, you and your doctor should agree on a target uric acid level (note that this is encapsulated in professional guidance from rheumatologists, but often overlooked in practice). The target level should normally be 5mg/dL.
For most gout sufferers it is better to aim for at least one year with a lower target in order to get rid of old uric acid deposits as quickly as possible (Effect of Urate-Lowering Therapy on the Velocity of Size Reduction of Tophi in Chronic Gout). For this reason, I recommend maximum allopurinol dose until you have been without a gout flare for six months, and all visible tophi are resolved.
For some gout patients, there might be medical reasons to restrict uric acid lowering medications. In this case, it might be necessary to accept a target higher than 5mg/dL. This must be managed by your doctor on a case-by-case basis.
Starting Allopurinol Dosing
Allopurinol should be started as soon as possible. Every day of delay means more destruction of joints and damage to organs. Skin, kidneys, and heart are most commonly damaged, but you will see in the gouty tophi guidelines that all organs are at risk. Specifically, ignore common bad advice to wait until your gout flare has subsided before starting allopurinol. Initiation of allopurinol at first medical contact for acute attacks of gout makes it quite clear that starting allopurinol dosing should not be delayed.
Allopurinol should be started at 100mg per day. This dose is rarely effective in achieving target uric acid levels, but it will reveal if you are susceptible to adverse reactions without danger. After two weeks, your doctor should confirm the lack of side effects with further blood tests for liver and kidney function.
The dose should then be increased to reach your target uric acid level. Blood tests for uric acid, liver function and kidney function should be repeated periodically and the allopurinol dose adjusted accordingly. Tests are likely to be monthly at the start of treatment, but less frequent once uric acid levels stabilize. You need to be tested at least once per year for the rest of your life.
Ending Allopurinol Dosing
There is a strong case for suggesting that, once started, you should never stop taking allopurinol. However, this “allopurinol for life” approach is more a safe fallback than best practice.
Certainly, you should not normally stop taking allopurinol once started except for clearly defined medical situations. There is a body of opinion that believes allopurinol should be stopped during a gout flare. This is absolutely wrong. The only time you should stop taking allopurinol is if you experience the serious adverse reactions that are listed on your product label information.
Allopurinol Dosing Vacation
Some authorities suggest that, with good ongoing monitoring and management, it is perfectly feasible to stop taking allopurinol for many months once it is established that all old uric acid deposits have dissolved. As techniques improve for measuring uric acid deposits, it may well be that future recommendations are for short periods of uric acid lowering treatments whenever deposits are detected inside the body.
Please note that, at the moment, this type of monitoring and management is beyond most medical practitioners. However, if you feel that you are a candidate for an “allopurinol vacation” you should discuss this with your doctor, referring to Using serum urate levels to determine the period free of gouty symptoms after withdrawal of long-term urate-lowering therapy
Leave Allopurinol Dosing to browse the Allopurinol guidelines.
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