Once many crystals have formed, they can shed into the joint, causing painful inflammation. Allopurinol works by lowering the amount of urate in your blood. Once your urate level is low enough, new crystals will stop forming and existing crystals will slowly dissolve. After a few years, all the crystals may dissolve. If this happens, there will be no more joint damage or gout attacks caused by these crystals, as long as you are taking allopurinol.
Because it can take a long time to dissolve the crystals, you may have more attacks of gout while this is happening. This is more likely if your urate levels are very high to begin with, or if you have had gout for a long time. Gout is a form of arthritis, causing intensely painful, red, hot and swollen joints often the big toe. Learn about the causes, symptoms and treatments. Allopurinol is often recommended as the first choice of treatment to control gout. If your doctor prescribes it as soon as you are diagnosed, it may prevent future attacks and joint damage.
You will usually be offered allopurinol if blood tests show that your urate level is high enough for urate crystals to form, especially if one or more of the following applies:. Allopurinol is taken as a tablet once a day. It is usually better to take it just after eating and the tablet should be swallowed with water. It is important to drink plenty of water during the day because this will help you get rid of more urate through your kidneys. Your dose of allopurinol may change over time, depending on the amount of urate in your body.
Your doctor may recommend that you do not start taking allopurinol until after an attack of gout has passed to avoid triggering further attacks. If this is not possible, it may be started when your inflammation is not too bad. It is likely that you will need to take allopurinol for the rest of your life to manage your urate levels.
Findings of calcium pyrophosphate crystals and normal serum uric acid levels on joint fluid analysis can differentiate pseudogout from gout. Septic arthritis may present without a fever or elevated white blood cell count; arthrocentesis is required to distinguish this condition from acute gout. Gout and septic arthritis can occur concomitantly, but this is rare. To achieve rapid and complete resolution of symptoms, treatment of acute gout should commence within 24 hours of symptom onset 20 Table 3 Oral corticosteroids, intravenous corticosteroids, NSAIDs, and colchicine are equally effective in treating acute flares of gout.
Indomethacin Indocin has historically been the preferred choice; however, there is no evidence it is more effective than any other NSAID. Intramuscular ketorolac appears to have similar effectiveness. First-line therapy; all NSAIDs are equally effective; adverse effects include gastric bleeding and kidney injury. No analgesic properties; gastrointestinal adverse effects are common; avoid use in patients with renal and hepatic insufficiency; contraindicated in patients receiving clarithromycin Biaxin.
Oral, intramuscular, or intra-articular routes, variable dosing e. Preferred therapy for patients in whom NSAIDs and colchicine are contraindicated; when discontinuing oral corticosteroids, taper to avoid rebound flares.
Information from reference Corticosteroids are an appropriate alternative for patients who cannot tolerate NSAIDs or colchicine. When gout is limited to a single joint, intra-articular corticosteroid injections may be preferable to systemic corticosteroids because of their lower adverse effect profile.
To reduce the risk of a rebound flare, preventive treatment and initiation of a tapered course of corticosteroids over 10 to 14 days is recommended after resolution of symptoms.
Colchicine is another treatment option for acute gout. Generic colchicine, which has been used for decades, did not undergo formal review by the U.
However, Colcrys is expensive, and generic colchicine is no longer available. In addition, colchicine does not have analgesic properties and may be less effective in treating acute flares when given beyond 72 to 96 hours after symptom onset. Common adverse effects include nausea, vomiting, and diarrhea. Serum urate—lowering therapy should be initiated to prevent recurrences in persons with a history of gout and any one of the following: at least two flares per year one per year in persons with chronic kidney disease stage 2 or greater , tophi, or a history of nephrolithiasis.
They should be monitored periodically to assess preventive therapy in patients with recurrent gout and a history of elevated urate levels. Therapy should continue indefinitely if there are ongoing signs or symptoms e.
Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. Pharmacologic options for prevention of chronic gout are outlined in Table 4. May cause reversible axonal neuromyopathy; may increase risk of rhabdomyolysis when used with statins or clarithromycin Biaxin.
High risk of nephrolithiasis; encourage hydration and urine alkalization with potassium citrate; multiple drug interactions. Allopurinol Zyloprim. Genetic testing recommended before initiating treatment in patients at risk of severe hypersensitivity skin reaction those of Han Chinese or Thai descent, regardless of kidney function, or Koreans with chronic kidney disease stage 3 or greater. Febuxostat Uloric. Information from references 21 and Historically, urate-lowering medication was thought to worsen acute gout flares, but recent evidence suggests that allopurinol Zyloprim can be started during an acute flare if it is used in conjunction with an NSAID and colchicine.
Treatment should continue for at least three months after uric acid levels fall below the target goal in those without tophi, or for six months in those with a history of tophi. Allopurinol, a xanthine oxidase inhibitor, is a first-line agent to prevent recurrent gout.
Dosing is guided by the target serum uric acid level. Febuxostat Uloric is a xanthine oxidase inhibitor that was approved by the FDA in Although febuxostat is superior to mg allopurinol at lowering serum uric acid levels, it is not more effective at reducing the frequency of gout flares. Colchicine prevents gout flares at a dosage of 0. The dose should be adjusted in patients with chronic kidney disease and when used with cytochrome P 3A4 or P-glycoprotein inhibitors.
Patients should be advised to stop taking colchicine and tell their physician if they experience leg weakness or pain. Treatment should be discontinued if any signs or symptoms of nerve or muscle damage are present. The rare risk of rhabdomyolysis is increased when colchicine is used concomitantly with statins or clarithromycin Biaxin , especially in older adults or those with chronic kidney disease; therefore, close monitoring is recommended. Probenecid increases urinary excretion of uric acid and is typically used as a second-line treatment because of numerous drug interactions.
Of particular concern, probenecid increases blood levels of methotrexate and ketorolac, which may result in severe toxicity.
Probenecid may be used in combination with allopurinol or febuxostat when one drug does not independently lower serum uric acid to target levels. Nephrolithiasis is a common adverse effect that may be avoided by high fluid intake and urine alkalization with potassium citrate.
Pegloticase Krystexxa is an intravenous uricase approved by the FDA in The mechanism of action involves metabolism of uric acid to allantoin. It is a third-line agent and is indicated for treatment of refractory gout.
The search included expert consensus statements, clinical reviews, and clinical trials. Search terms included gout, gouty arthritis, gout prevention, and gout therapy.
Search date: May Already a member or subscriber? Log in. And 59 percent of the DE group achieved and maintained the target urate level for the last three months of the study.
When urate-lowering therapy is started, patients have an increased risk of a gout attack as uric acid levels drop rapidly, explains Dr. However, taking the drug colchicine for the first six months of allopurinol therapy can help prevent the attacks, he says.
Once serum urate levels are lowered to the target, it takes a while for the crystals to dissolve and flares to diminish. We hope this data will be published in the next few months. Stamp encourages patients to take control. If you are still having regular attacks or have tophi, talk to your doctor. It is important that your blood uric acid levels are checked and your urate-lowering medicines adjusted to reduce your uric acid and improve your symptoms. Kay agrees. Beth Axtell for the Arthritis Foundation.
Go to Get someone else to drive you or call for an ambulance. Take the allopurinol packet or leaflet inside it, plus any remaining medicine, with you. Like all medicines, allopurinol can cause side effects, although not everyone gets them. The most common side effects are feeling or being sick.
These can be reduced if you eat little and often and drink lots of fluids such as water or squash. If you are being sick, take small, frequent sips of water to avoid dehydration. If you notice a skin rash or redness, tell a doctor straight away, as this can develop into a life-threatening skin condition called Stevens-Johnson syndrome. Stevens-Johnson syndrome is a rare side effect of allopurinol.
It causes flu-like symptoms, followed by a red or purple rash that spreads and forms blisters. The affected skin eventually dies and peels off. It's more likely to happen in the first 8 weeks of taking allopurinol, or when the dose is increased too quickly. It can also happen if allopurinol is stopped suddenly for a few days and then restarted at the same dose as before.
It's better to reduce the dose and then increase it slowly. It's also best to not start taking allopurinol within 2 weeks of a viral infection, vaccination, or rash caused by something else. It's unusual to have serious side effects after taking allopurinol. Tell a doctor straight away if you:. In rare cases, it's possible to have a serious allergic reaction anaphylaxis to allopurinol. These are not all the side effects of allopurinol.
For a full list, see the leaflet inside your medicines packet. Allopurinol is not usually recommended during pregnancy. There is not enough evidence to say that it's safe. Talk to a doctor if you're thinking about trying for a baby. There may be other medicines that are safer for you. If your doctor or health visitor says your baby is healthy, allopurinol can be taken while you're breastfeeding. Allopurinol passes into breast milk in small amounts and has been linked with side effects in very few breastfed babies.
If you notice that your baby is not feeding as well as usual, or seems unusually sleepy, or if you have any other concerns about your baby, then talk to your health visitor or doctor. Some medicines and allopurinol can interfere with each other and increase the chances of you having side effects. Tell a doctor or pharmacist if you're taking any of these medicines before you start taking allopurinol:.
If you take aluminium hydroxide found in some antacids such as Maalox and Mucogel , leave a 3 hour gap between the aluminium hydroxide and your allopurinol dose. You can take allopurinol with paracetamol and anti-inflammatory medicines such as ibuprofen , naproxen , or indomethacin. Your doctor may prescribe a NSAID such as diclofenac or naproxen or a medicine called colchicine to help prevent or to deal with attacks of gout — especially in the early stages of allopurinol treatment.
There's very little information about taking herbal medicines and supplements with allopurinol. Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements.
In gout, this helps prevent uric acid crystals building up in the joints. This helps prevent joints becoming swollen and painful. In cancer, some cancer treatments kill cancer cells and uric acid is then released from these cells.
The build-up of uric acid into crystals can damage the kidneys. In kidney stones, the waste products in the blood including uric acid can make crystals that collect inside the kidneys.
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