Ensure adequate allopurinol – titrate to serum urate

He Ako Hiringa
1 March 2024

Ensure adequate allopurinol – titrate to serum urate

The most commonly used maintenance dose of allopurinol is 300mg daily, but this dose may not reduce serum urate enough to suppress gout flares.1–4 Combined with evidence that it is the starting dose of allopurinol, not the maintenance dose, that increases the risk of allopurinol hypersensitivity syndrome,5 starting with a low dose and slowly escalating to reach the serum urate target is crucial.

Allopurinol therapy requires significant commitment from both patient and healthcare provider as gout flares may initially worsen, and monthly blood tests are required. Involve a multidisciplinary team where possible, eg, doctor, nurse, pharmacist, social worker, kaiāwhina, health coach, health improvement practitioner, podiatrist and Arthritis New Zealand supports.

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  1. Drug and Therapeutics Bulletin. Latest guidance on the management of gout. BMJ. Published online July 18, 2018:k2893. doi:10.1136/bmj.k2893
  2. Stamp LK, Chapman PT, Barclay ML, et al. A randomised controlled trial of the efficacy and safety of allopurinol dose escalation to achieve target serum urate in people with gout. Ann Rheum Dis. 2017;76(9):1522-1528. doi:10.1136/annrheumdis-2016-210872
  3. Stamp LK, Frampton C, Morillon MB, et al. Association between serum urate and flares in people with gout and evidence for surrogate status: a secondary analysis of two randomised controlled trials. The Lancet Rheumatology. 2022;4(1):e53-e60. doi:10.1016/S2665-9913(21)00319-2
  4. O’Dell JR, Brophy MT, Pillinger MH, et al. Comparative Effectiveness of Allopurinol and Febuxostat in Gout Management. NEJM Evidence. 2022;1(3). doi:10.1056/EVIDoa2100028
  5. Stamp LK, Taylor WJ, Jones PB, et al. Starting dose is a risk factor for allopurinol hypersensitivity syndrome: a proposed safe starting dose of allopurinol. Arthritis Rheum. 2012;64(8):2529-2536. doi:10.1002/art.34488