Allopurinol should be started at a dose of 100 mg od and titrated upwards in 100 mg increments on a monthly basis, with the aim of getting the urate <0.36 – some experts say to aim for <0.3 for the first couple of years to speed up crystal dissolution, then between 0.30 & 0.36 thereafter. Monitor not just urate, but FBC, LFTs & U&Es as well. Renal failure is a risk factor for allopurinol hypersensitivity syndrome, as are diuretics and high initial doses.
There’s less evidence than you might think for the claim that allopurinol shouldn’t be started during an acute attack – one small RCT did not find a difference in pain levels between starting allopurinol during the attack and starting it later. Not that I think I’d have the nerve to.
There’s evidence for the role of both weight loss and low-purine diets (reduced meat & seafood, reduced alcohol especially beer) in reducing frequency of gout attacks. However, the advice to increase dairy products, Vitamin C and coffee and decrease fructose/sweetened soft drinks all has minimal evidence behind it.
(BMJ 2013;347:f5648, doi:101136/bmj.f5648)