If you have a gout flare while taking allopurinol, you should generally keep taking your prescribed dose rather than stop because your joint is painful. Allopurinol lowers urate over time to help prevent future flares; it does not relieve the pain of an attack. With gout and allopurinol, treating a flare and deciding whether to start long-term urate-lowering treatment are separate decisions.
gout and allopurinol: what to do during a flare
Allopurinol is a urate-lowering therapy (ULT). It helps reduce the urate that can form crystals in joints, but it does not quickly settle inflammation once a flare is underway. A flare can still happen while you take it, particularly during the early stages of treatment or while your dose is being adjusted. A flare does not, by itself, show that the medicine has failed.
Guidelines recommend continuing established ULT during a flare. Stopping and restarting on your own can disrupt a long-term treatment plan. If you have been told to pause it for a specific reason, or you are concerned about a possible side effect, contact the clinician who prescribed it rather than relying on the general rule.
A flare needs its own treatment. The American College of Rheumatology (ACR) guideline lists anti-inflammatory medicines such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids as options for treating flares. Which option is suitable depends on your health and other medicines; kidney disease and other conditions can affect that choice. Ask your clinician or pharmacist what plan applies to you.
Can you start allopurinol during a flare?
Guidance is not identical across countries. The ACR’s 2020 US guideline conditionally recommends that ULT can be started during a flare. “Conditionally” means the decision should be individualised, rather than that starting during every flare is preferred. The guideline notes that some trial evidence did not show a large risk of prolonging a flare. It also recognises that discussing long-term treatment can be difficult when you are in severe pain.
In the UK, NICE guidance generally recommends starting ULT two to four weeks after a flare has settled. It also allows starting during a flare when someone has frequent flares. NICE’s evidence review found no direct comparison of starting at different times: the studies it considered started treatment during a flare. So the recommendation reflects limited evidence and committee judgement, not proof that waiting is better for everyone. Guidance and practice can vary elsewhere; ask your local clinician how they approach the timing.
What the research can—and can’t—tell you
In 2016, Fatma Eminaga and colleagues published a systematic review of trials that started ULT during an acute gout attack. They identified three randomised controlled trials. In two higher-quality studies, early allopurinol did not increase pain severity at days 10–15. Across three studies, starting ULT was not linked to more treatment dropouts. The review judged the evidence moderate quality, but noted that larger studies were needed.
That finding supports the view that starting during a flare may be reasonable for some people. It does not establish that the timing is equally suitable for everyone, or that starting during a flare shortens it. The trials were small in number, and NICE noted that they did not compare starting during a flare with waiting until it had resolved. This is why the US recommendation is conditional and UK guidance makes room for both timing approaches in particular circumstances.
Make a plan with your clinician
If you already take allopurinol, ask whether your flare-treatment plan needs updating, but don’t stop the daily medicine simply because a flare has started. If you are considering starting it, discuss the timing, how the dose will be managed, and whether you need anti-inflammatory prevention while treatment begins. The ACR recommends preventive anti-inflammatory treatment when starting ULT, usually for at least three to six months, with the choice tailored to the person.
If this is your first painful, swollen joint, or the symptoms are unusual for you, get medical advice rather than assuming it is gout. Other joint problems can resemble a flare, and a clinician can help confirm what is happening and choose appropriate treatment.
