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Renal dosing of allopurinol results in suboptimal gout care
  1. Tuhina Neogi1,
  2. Nicola Dalbeth2,
  3. Lisa Stamp3,
  4. Geraldo Castelar4,
  5. John Fitzgerald5,
  6. Angelo Gaffo6,7,
  7. Ted R Mikuls8,
  8. Jasvinder Singh7,
  9. Janitzia Vázquez-Mellado9,
  10. N Lawrence Edwards10
  1. 1Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
  2. 2Department of Immunology, University of Auckland, Auckland, New Zealand
  3. 3Department of Medicine, Otago University, Christchurch, Canterbury, New Zealand
  4. 4Department of Rheumatology, Pedro Ernesto University Hospital, Rio de Janeiro, Brazil
  5. 5Medicine/Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
  6. 6Department of Medicine, Birmingham VA Medical Center, Birmingham, Alabama, USA
  7. 7Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
  8. 8Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
  9. 9Servicio de Reumatologia, Hospital General de Mexico, Mexico City, Mexico
  10. 10Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
  1. Correspondence to Professor N Lawrence Edwards, University of Florida, Gainesville, FL 32610, USA; edwarnl{at}

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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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