In this blog post, I’ll share my top 5 gout pharmacotherapy pearls. This can often show up in practice as well as on those challenging board exams!
Allopurinol Doesn’t Treat Flares
Allopurinol reduces the production of uric acid. Because of this mechanism, the drug is not beneficial in the relief of pain and inflammation in an acute gout flare. Allopurinol is only indicated to reduce uric acid and prevent gout flares. Starting allopurinol or increasing the dose of the medication is not typically recommended or helpful during an acute flare. We need to use NSAIDs, steroids, or colchicine to help alleviate the pain and inflammation of an acute flare.
CKD Awareness With Allopurinol
Allopurinol should be started at low doses (typically 100 mg daily or less) and titrated gradually every 2–5 weeks based on serum uric acid levels. This approach reduces the risk of gout flares and improves tolerability. Chronic kidney disease is not a contraindication to allopurinol, but it does require slower titration and closer monitoring. The goal serum uric acid is usually less than 6 mg/dL. In patients with CKD, there is also a higher likelihood of rash and Stevens-Johnson Syndrome, and this is especially true if dosing is too aggressive. Also recall that the HLA-B*58:01 allele dramatically increases the risk of allopurinol-induced SJS/TEN. This allele is more prevalent in certain populations (e.g., Han Chinese, Korean patients with stage ≥3 CKD, Thai, and some African ancestry groups). CKD plus HLA-B*58:01 greatly magnifies risk.
Anticoagulation and Renal Disease
Flare management is important. NSAIDs are most commonly selected as the drug of choice to treat pain and inflammation. There are cases where NSAIDs shouldn’t be used, and we may prefer to utilize corticosteroids or colchicine. The two most common cases to avoid NSAIDs are in those taking anticoagulants or who have preexisting renal disease.
Thiazides Raise Uric Acid, Losartan Can Lower
Thiazide diuretics increase uric acid levels and are common contributors to gout flares. When possible, consider alternative antihypertensives such as losartan, which can lower uric acid. Alcohol intake (especially beer), high-fructose beverages, red meat, and seafood are frequent dietary triggers. Addressing these contributors is just as important as pharmacologic therapy.
Colchicine
Colchicine has a narrow therapeutic index and requires careful dosing, particularly in older adults and those with renal impairment. The preferred regimen for acute flares is a low-dose strategy, which is equally effective and far safer than older high-dose approaches. Diarrhea is the most common dose-limiting adverse effect. Major drug interactions, especially with strong CYP3A4 or P-gp inhibitors, can dramatically increase colchicine toxicity and should always be screened for.
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