Is as needed (PRN) allopurinol appropriate?
I have seen as-needed (PRN) orders for allopurinol in practice. It has been rare, but it has happened. Did I like it? No. Allopurinol helps to lower uric acid levels. Allopurinol inhibits xanthine oxidase which is an enzyme that is necessary for the production of uric acid. While the drug starts inhibiting this enzyme relatively quickly, lowering uric acid levels takes some time. Because of this fact, using allopurinol for the acute management of a gout flare doesn’t make a lot of sense. A patient is unlikely to experience any benefit from the medication when it is needed (right now). It will take a couple of days at least to begin working with peak uric acid lowering effects in 1-2 weeks. Bottom line: I don’t know of a good rationale to use allopurinol on an as-needed basis.
NSAIDs or corticosteroids as needed will make a lot more sense. They directly reduce inflammation and pain associated with a gout flare. Allopurinol won’t do either of these things so it will be useless for the acute relief of those issues related to a flare.
Can I start taking allopurinol during an acute gout flare?
Another question I’ve been asked before with regard to allopurinol is “Can I start it during an acute attack?” This has been a much more controversial topic. There has always been the theory that starting allopurinol during an acute attack will actually make the flare worse or possibly last longer. The most recent evidence I can find (which is from a while ago) is from 2015. This article (Hill et al.), albeit with small sample size, did show that there were no issues associated with starting allopurinol during an acute attack. Some clinicians will still wait to start allopurinol while others will initiate it with a medication to treat the acute flare.
Looking for more on allopurinol? Check out this must know drug interaction!
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