Predicting Gout Flares in People Starting Allopurinol Using the Start-Low Go-Slow Dose Escalation Strategy

Objective

The study objective was to determine predictors of gout flare when commencing allopurinol using the “start-low go-slow” dose escalation strategy.

Methods

A post hoc analysis of a 12-month double-blind placebo-controlled noninferiority trial with participants randomized 1:1 to colchicine 0.5 mg daily or placebo for the first six months was undertaken. Multivariate logistic regression models were used to identify independent predictors of gout flares in the first and last six months of the trial.

Results

Multivariable analysis revealed a significant association between risk of a gout flare in the first six months and flare in the month before starting allopurinol (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.36–5.17) and allopurinol 100 mg starting dose (OR 3.21, 95% CI 1.41–7.27). The predictors of any gout flares in the last six months of the trial, after stopping colchicine or placebo, were having received colchicine (OR 2.95, 95% CI 1.48–5.86), at least one flare in the month before stopping study drug (OR 5.39, 95% CI 2.21–13.15), and serum urate ≥0.36 mmol/L at month 6 (OR 2.85, 95% CI 1.14–7.12).

Conclusion

Anti-inflammatory prophylaxis when starting allopurinol using the “start-low go-slow” dose escalation strategy may be best targeted at those who have had a gout flare in the month before starting allopurinol and are commencing allopurinol 100 mg daily. For those with ongoing gout flares during the first six months of starting allopurinol who have not yet achieved serum urate target, a longer period of prophylaxis may be required.