Allopurinol for Gout: How it Works, Why It’s Prescribed, and More
allopurinol for gout

It is well established that gout is caused by a buildup of uric acid in the blood, leading to accumulation around the joints that causes painful flares of joint pain, swelling, and discomfort. Tophi (those large, painful bumps associated with gout), are deposits of uric acid crystals that collect around the joints, primarily around the big toes, ankles, knees and hands. Allopurinol for gout is a pill that is often one of the first choices of treatment to lower uric acid levels in the body.

Why is Allopurinol Prescribed for Gout?

Allopurinol, including the brand names Zyloprim, Aloprim, and Lopurin, is a type of medication known as a xanthine oxidase inhibitor. The medication works by preventing the creation of xanthine oxidase, which is what causes uric acid to form and build up in the body. When uric acid is not collecting in the body, the chances that gout worsens over time is significantly lower. So by lowering blood levels of uric acid, the underlying reason that gout happens is being treated.

When we eat foods that contain purines (a natural chemical compound), the body converts them into uric acid as a waste product. Normally, uric acid is liquid in the blood and leaves the body through specific pathways in the kidneys as urine. When there is too much uric acid for the body to get rid of and crystals or solid clumps of uric acid begin to form and present as gout, allopurinol is a medication that helps to lower that buildup and ultimately prevent future flares from happening.

Allopurinol for gout is not a medication that treats the pain and swelling associated with a gout attack. That is why many need more than one gout medication to treat the underlying issue of uric acid buildup in addition to a medication to treat the pain of a flare. When the flares stop happening because the blood uric acid level is low enough, then the medications used for attacks or flares are usually stopped and you then remain on allopurinol to maintain your lower uric acid levels.

What is the Standard Allopurinol Dose?

Your exact dose of allopurinol for gout will be determined by your rheumatologist or provider based on the severity of your symptoms. For most patients with gout, the starting dose of allopurinol is typically between 100 and 300 mg per day. Your rheumatologist may increase the dose of allopurinol if needed based on a target uric acid goal, but it likely won’t exceed 900 mg daily. The entire dose of allopurinol can be taken at once during the day and this makes it much easier to remember your full dose so you are not skipping part of your medication if you accidently forget.

Much like blood pressure medication is adjusted to reach a certain blood pressure number (or range), allopurinol should be adjusted to reach a certain uric acid goal or range. This is determined based on the presence of gouty arthritis, presence of tophi, lifestyle and diet preferences, as well as the number of flares per year. If you are on allopurinol for gout and your dose has never been adjusted by your provider, it is important to ask that you are on the best dose for your body, especially if you continue to have gout flares while you are taking allopurinol consistently.

Can Allopurinol Worsen Acute Gout?

Some patients notice that they temporarily experience increased gout flares while taking allopurinol for gout. This is common to happen in the beginning when starting allopurinol or if your dose is being adjusted. Gout flares while taking allopurinol can be a sign that the medication is working if you have just started a new prescription or if you are in the process if increasing your dose to lower your uric acid level even farther. If you have been on a stable dose of allopurinol for gout and continue to have gout flares, this can be a sign that you still have high levels of uric acid and your medication may not be the right dose for your body.

Gout Attack While Taking Allopurinol

When allopurinol prevents uric acid crystals from forming, the existing crystals will begin to break down and dissolve. Sometimes, crystals in the blood may decrease in size and settle in the joints, causing a temporary flare. This is an expected process of treating gout and can be managed with small adjustments in the dose of allopurinol over time and treating the flare with other medications that decrease the inflammation and pain associated with gout like colchicine, prednisone, or other medications for gout flares.

Not all patients who take allopurinol for gout notice an increase in gout flares while taking the medication. Your rheumatologist will monitor your gout symptoms throughout your course of treatment and prescribe additional pain medication if needed.

If you experience an acute gout attack while taking allopurinol, it is very important that you do not stop taking your medication before consulting with your rheumatologist. Having a flare does not mean that you are having a side effect to this medication. As mentioned, it is also possible that the particular dose of allopurinol you are taking might not be the best dose for your individual uric acid level. This is why it is important to have regular follow-up visits and lab tests to monitor your progress while treating gout.

Allopurinol vs Colchicine

Colchicine is a medication known as an NSAID (non-steroidal anti-inflammatory drug). Unlike ibuprofen, colchicine is not available over the counter and must be prescribed by your rheumatologist or provider. Colchicine is typically a second line of treatment for gout pain when more traditional NSAIDs are not effective at reducing pain, or if you have a condition in which you are not able to take traditional NSAIDs (like ibuprofen/motrin, or naproxen/aleve). Colchicine is a pill or capsule and works by reducing inflammation caused by uric acid crystals that trigger gout attacks or flares. The most common dose is 0.6 mg 1-2 times daily. Some patients can take up to 3 tabs daily and this dose may be limited by upset stomach, so often a lower dose is preferred.

Colchicine is used to relieve gout pain, and is not effective at treating the underlying cause of gout. Therefore, your provider may prescribe colchicine plus allopurinol as a part of your gout treatment plan.

Contraindications to Allopurinol

Allopurinol for gout is generally considered safe for many individuals, but may not be the best fit if you have one of the following conditions:

  • Pregnant or breastfeeding
  • History of allergic reaction to allopurinol
  • Actively taking the medication azathioprine (commonly used in transplant patients)
  • HLA B50*01 gene in certain populations of African American or Asian descent

Your provider will determine if allopurinol is an appropriate medication to treat your gout symptoms. If you have any questions about allopurinol contraindications or side effects, it is important to discuss these questions with your rheumatologist or provider.

Allopurinol and Alcohol

If you have been prescribed allopurinol for gout, it is recommended that you limit alcohol consumption during treatment. While alcohol isn’t known to interact with allopurinol, alcohol is known to worsen gout symptoms and increase the risk of a gout flare. Alcohol, especially beer, is high in purines, the substance that converts to uric acid in the body. Alcohol also can affect liver function and if your liver tests are abnormal, it can be difficult to determine if alcohol is irritating your liver or if medication is the cause. While beer has the highest amount of purines, it has been shown that alcohol consumption, regardless of type, may be associated with increased gout attacks.

If you are currently taking allopurinol for gout or have questions about how the medication may fit into your gout treatment plan, reach out to our rheumatology team at Summit Rheumatology. Our gout specialists provide treatment for all stages of gout and are passionate about helping gout patients find relief from their symptoms.

We are currently accepting new gout patients and in-person or telemedicine options are available! Give us a call at (480) 494-2770 or send us a message to schedule your appointment.

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