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We commend the authors of the ‘2016 updated EULAR evidence-based recommendations for the management of gout’ for advocating starting allopurinol at a lower dose in patients with normal renal function.1 Specifically, this recognises an approach to potentially decrease the risk of precipitating flares of gout early in the course of urate lowering, and also to possibly decrease the risk of severe cutaneous reactions (SCARs) compared with higher starting doses of allopurinol.2 However, we note that the authors do not provide a recommendation on starting dose for patients with renal impairment, the patient group most likely to benefit from starting at a much lower dose of allopurinol.2
Furthermore, recommendation #9,i which advocates limiting the maximal dose of allopurinol based on creatinine clearance (CrCL), is concerning. It is well-documented that such practice results in suboptimal management of hyperuricaemia in the majority of …
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