Treatment of Gout with Allopurinol Allergy or Intolerance
Patients with gout who develop an allergy or intolerance to allopurinol require a tailored approach to both acute flare management and longer-term care — the standard first-line urate-lowering agent is not an option in this population.
This protocol addresses gout in the presence of a documented allopurinol allergy or intolerance. Because allopurinol cannot be used, management decisions must account for this constraint from the outset, affecting both acute treatment choices and urate-lowering strategy.
Acute gout flares in this setting are managed with anti-inflammatory therapy, and early treatment initiation is a key principle. The full protocol specifies which agents apply and how they are selected in this clinical context.
Resolution of the acute gout flare, with relief of joint pain and inflammation.
- Acute flares of gout should be treated as early as possible.
- Recommended first-line options for acute flares are colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30-35 mg/day of equivalent prednisolone for 3-5 days) or articular aspiration and injection of corticosteroids.
- In Europe, colchicine is available in 1 mg tablets, so the task force recommends the use of 1 mg colchicine followed 1 hour later by 0.5 mg for treating flare.
- A double-blind, randomised equivalence trial of crystal-proven gout from a primary care source population found that prednisolone (35 mg/day for 5 days) was equivalent to naproxen (500 mg twice a day for 5 days) for treating flare.
- Febuxostat or a uricosuric are also indicated if allopurinol cannot be tolerated.
- If the SUA target cannot be reached by an appropriate dose of allopurinol, allopurinol should be switched to febuxostat or a uricosuric, or combined with a uricosuric.