Allopurinol for gout: read on to discover why allopurinol may not be as effective as it could be, how it can actually trigger a gout attack, but why it’s inadvisable to stop taking your allopurinol during one.
Allopurinol for Gout
Allopurinol has been around for over 50 years and is the most commonly prescribed drug for the prevention of recurring gout. It comes under the class of drugs called xanthine oxidase inhibitors.
Xanthine oxidase (XO) is a natural enzyme in the body that helps to convert purines into uric acid. So if this reaction can be slowed down then less uric acid will be produced, blood uric acid levels will fall, and the risk of a gout attack will be reduced.
And that’s what allopurinol does: It works by inhibiting the ability of the enzyme to produce uric acid in the bloodstream.
The problem is that it only works while it’s being taken. Once stopped, the inhibition of XO also stops, so your uric acid levels can rise again, which is why allopurinol is usually taken for life.
Allopurinol is generally started between 2 and 3 weeks after a gout attack has abated. The recommended dosage is between 100mg and 300mg per day usually in one oral dose. But for some people higher doses of up to 800mg per day may be required initially.
And it may take some months before your doctor arrives at the correct dosage for your particular case; perhaps starting off with 1 x 100mg tablet per day. The objective is to get your blood uric acid down, and stable, below 6mg/dl.
How Effective is Allopurinol for Treating Gout?
At least one study indicates that it may not be as effective as it could or should be…
In October 2013, the results of a large study on the effectiveness and safety of allopurinol in treating gout was presented to the American College of Rheumatology (ACR) Annual Meeting in San Diego, California, by AstraZeneca and Ardea Biosciences.
The multinational study, called LASSO (Long-term Allopurinol Safety Study Evaluating Outcomes in Gout Patients), involved 1,735 gout patients over a 6 month period.
Using a target serum uric acid level (sUA) of <6.0 mg/dL — the level recommended by the ACR and the European League Against Rheumatism (EULAR) — the investigators measured each patient’s blood uric acid level during and at the end of the 6 month study period to ascertain how many patients reached the recommended target. The study had asked investigators to increase allopurinol over the course of the study to a medically appropriate dose for each patient.
The results indicated that less than 43% of all patients in the study reached the target level of <6.0 mg/dL. And, of those patients who had had final doses above the most common dose of 300 mg/day, only 54% achieved target levels of <6.0 mg/dL. The results seem to chime with other published literature on the subject. In terms of safety, the study did not find any issues that weren’t already known.
Co-author of the study, Nicola Dalbeth, MD of the University of Auckland, commented:
“Failing to reach the recommended sUA target leaves patients with gout at risk for further disease progression and long-term consequences of gout.”
An important point to consider here is that although patients in the study were given allopurinol doses appropriate to their condition, less than 50% managed to get their uric acid below 6.0 mg/dL and given that, even today, gout is still often misunderstood and inadequately treated, it must mean that even more gout patients are not reaching their treatment goal, with all the risks that that entails.
It would seem that allopurinol, at least as it’s being prescribed today, is not giving sufficient patients the outcomes hoped for. This is worrying because recent research has indicated that hyperuricemia isn’t only linked to gout, but also to diabetes, kidney problems, heart disease, and an increased risk of death.
The other issue surrounding allopurinol is that it does have many side effects such as nausea, abdominal pain, upset stomach, diarrhea, joint stiffness, and skin problems. Of course, the majority of patients taking allopurinol won’t suffer any side effects, but those that do need to seek advice from their doctor right away.
Taking Allopurinol for the First Time
When taking allopurinol for the first time you may experience another gout flare (the first being the one that took you to your doctor in the first place). But don’t be alarmed, this happens in around 75% of cases, so you won’t be alone.
It isn’t exactly clear why this happens, but one thought is that, as the allopurinol produces a relatively fast reduction in blood uric acid that partially dissolves existing uric acid crystals, the now smaller crystals are able to move from the cartilage into the joint cavity, where they inflame the soft synovial membrane.
But when this happens don’t stop taking your allopurinol…
Why You Shouldn’t Stop Taking Your Allopurinol
At least one study has shown that uric acid levels can rise rapidly when the medication is stopped and can reach pretreatment levels within a week, irrespective of how long the patient had been taking allopurinol.
And it’s possible to have multiple gout flares, whilst you are taking allopurinol, until all gout crystals have been dissolved and your uric acid levels are under control, which may take some time.
So if you were to stop taking your allopurinol every time you had a gout attack you’d be continually setting your recovery back to day 1 each time you did.
Don’t stop the medication, but do contact your doctor. They will usually reduce your allopurinol dose or prescribe a non-steroidal anti-inflammatory drug (NSAID) to help reduce the inflammation and pain. They may even do both.
And if NSAIDs are ineffective or inappropriate for you, they may prescribe colchicine instead, a powerful drug that works by reducing the number of white blood cells flooding into the affected area; so helping to reduce swelling and relieve pain.
I know it can be soul-destroying to be taking a medication which seems to trigger the very thing it’s meant to prevent! But to reach your goal of finally getting your uric acid levels under control you have to stick with it. Once your doctor has found the correct allopurinol dosage and you have your uric acid levels under control, below 6mg/dl, you’ll reap the benefits.
But, bear in mind that there are natural ways to relieve painful gout symptoms and prevent future attacks...
Natural Xanthine Oxidase Inhibitors?
Several studies have indicated that certain flavonoids in fruits such as cherries may inhibit xanthine oxidase and help lower uric acid.
In addition, there are numerous herbs said to lower uric acid by inhibiting xanthine oxidase in the same way as allopurinol, with some being at least 87% as effective as allopurinol.
Some of the most potent are to be found in North America:
- Balsam Poplar
- Labrador Tea
- Common Speedwell
and in Australia:
- Spotted Emu Bush
- Australian Blackwood
- Marsh Syemodi
And, if you didn’t want to depend entirely on natural remedies, they can be used to help the effectiveness of your drug regimen. But, of course, talk to your doctor first.