ELAG: Similar gout flare outcomes with early vs late allopurinol initiation
medwireNews: Early initiation of allopurinol during an acute gout flare does not impact time to resolution or rates of recurrent flare, suggest findings from a randomized controlled trial.
“Allopurinol initiation in acute gouty arthritis is sometimes delayed due to concerns regarding the prolongation of acute flare,” and current guidelines on when to initiate urate-lowering therapy (ULT) are conflicting, say the study authors.
“The 2017 British Society for Rheumatology guidelines recommend that ULT should be delayed until inflammation has settled,” whereas “the 2020 American College of Rheumatology guidelines for gout management conditionally recommend that pharmacologic ULT may be initiated during an acute gout flare,” they explain.
The open-label ELAG trial included 115 people with recent onset (≤72 hours) acute gouty arthritis who were randomly assigned to initiate allopurinol on day 1 or day 14, with dosing based on kidney function. Participants were aged a median of 62 years, and initial treatment for gout flare was similar in the early and late allopurinol groups, with colchicine taken by 41.3% and 45.6%, prednisolone by 31.0% and 38.6%, and nonsteroidal anti-inflammatory drugs by 27.6% and 15.8%, respectively.
Panchalee Satpanich and colleagues from Navamindradhiraj University in Bangkok, Thailand, found that there was no significant difference in the time to complete gout flare resolution with early versus late initiation of allopurinol, at a median of 6 days in both groups. Complete flare resolution was defined according to the absence of swelling or warmth, a tenderness score of 1 or lower on a 4-point Likert scale, and a VAS pain score of 2 points or lower or at least a 50% reduction from baseline in the involved joint.
Similarly, the median time to clinical resolution – determined according to the same VAS criteria used in the definition of complete resolution – was 4 days in both the early and late allopurinol groups, and there was no significant difference in rates of arthritis relapse, at 20.69% and 15.79%, respectively.
Mean serum uric acid levels at day 14 were significantly lower in the early compared with the late allopurinol group (7.15 vs 8.70 mg/dL), but there was no significant difference at the 28-day follow-up (6.55 vs 7.00 mg/dL). Satpanich and team note that levels of acute-phase reactants and C-reactive protein, as well as erythrocyte sedimentation rate, were also comparable in the two groups at 28 days.
“In conclusion, early allopurinol initiation during an acute gout flare was not associated with significant changes in time to resolution, recurrent flares, or inflammatory marker levels,” write the researchers in Clinical Rheumatology.
And they suggest that “acute gout flare might be a window of opportunity to start ULT.”
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