Does Allopurinol Dissolve Tophi?
Guidelines tell us that patients with gouty tophi should initiate allopurinol or similar uric acid treatment. But does this mean that allopurinol will dissolve tophi? Recently, I have reviewed the discussion that first asked, "does allopurinol dissolve tophi?"
In truth, that is like asking if sunshine will melt ice! Because the temperature-increasing properties of sunshine can indeed melt ice in the right circumstances. But it is less confusing to think that sufficient heat melts ice. Therefore, the important property of allopurinol in this context is that it causes lower levels of uric acid. So for tophi to dissolve, the concentration of uric acid must fall below its crystallization point.
There is a case study that explains the important factors that cause tophi to dissolve after allopurinol initiation. So in this article, I explain allopurinol and tophi concerns with respect to my original forum discussion, current guidelines, that case study, and related gout sufferer concerns.
Tophi and Allopurinol DiscussionIn our tophi and allopurinol discussion, we discussed different aspects of dissolving tophi when taking allopurinol. However I inadvertantly linked the wrong research to this discussion. So the language might not be exact. But all the science linked to that discussion and this review supports the fact that allopurinol can reduce the size of tophi. Sometimes this is called "dissolving". However, similar terms such as "shrink", "decrease", "reduce", "resolve", or "involution" indicate the same process. Importantly, all references indicate that it is the ability of allopurinol to lower uric acid that causes tophi to dissolve.
Allopurinol & Tophi Guideline
The first strong recommendation for gout sufferers with tophi is to initiate ULT. That is Urate Lowering Therapy. Which I usually refer to as uric acid treatment. Another strong recommendation is that allopurinol is the first choice of uric acid treatment. But recommended allopurinol dosage is something that you and your doctor need to determine between you. Because your medical history and preferences will determine how quickly you allow allopurinol to dissolve your tophi. There is a lot of detail in the gout guideline to help you and your advisers. In a nutshell...
Strong recommendations included initiation of ULT for all patients with tophaceous gout [...]
The Voting Panel strongly recommended allopurinol as the preferred first-line agent given its efficacy when dosed appropriately [...]
There is ample evidence that lower SU levels hasten the resolution of tophi
Allopurinol Unlocks Tophi Study
Case studies often give extra details that help you and your advisers match your situation with recommended options from the guidelines. So the 2008 study of allopurinol and tophi is relevant here.
In this study, a gout patient suffered from a loss of mobility. Because tophi had locked his knee. However, the usual procedure of tophi removal by surgery was unavailable. Due to the patient taking blood thinners. So they tried allopurinol to reduce uric acid levels.
They began with a safe allopurinol starting dose of 100 mg per day. Then titrated up to 300 mg per day to try and dissolve the tophi.
Evidence suggests that serum uric acid levels should be lowered to below 357 μmol/l [6 mg/dL] in order to reduce crystal load, dissolve tophi and prevent acute attacks of gout. [...]
Unlocking of the knee and relief from pain occurred 3 months after the dose increase.
Related Allopurinol & Tophi ConcernsWhile reviewing the articles mentioned here, I discovered related concerns about allopurinol and tophi. So I will explain those in separate articles about tophi concerns. Gout sufferers are also concerned about:
what happens if you take too much allopurinol
do uric acid crystals dissolve
I will add those to common concerns within the Allopurinol Section and the Uric Acid Section, respectively. But for now, you should search for relevant information.
Will Allopurinol Dissolve Your Tophi?
Now, you should understand that allopurinol can indirectly dissolve your tophi. But only if you work with your doctor to maintain uric acid at a low enough level. So make sure your GoutPal Patient Plan is on target for that.
If you still have concerns about allopurinol and tophi, you must discuss them with your doctor. So to help you prepare for those discussions, you can add personal notes here. I recommend that you do this as part of my Contributor Notes scheme. But these are your notes. So feel free to use whichever tools you and your advisers are most comfortable with. If you prefer less formality, contact me>.
Allopurinol Dissolves Tophi References
- FitzGerald, John D., Nicola Dalbeth, Ted Mikuls, Romina Brignardello‐Petersen, Gordon Guyatt, Aryeh M. Abeles, Allan C. Gelber et al. "2020 American College of Rheumatology Guideline for the Management of Gout." Arthritis Care & Research (2020).
- GoutPal Forum Members. "Tophi and Allopurinol Discussion." Original GoutPal Forum (Feb 2007): Archive accessed 7 Aug 2020.
- Chatterjee, Soumya, and Hakan Ilaslan. "Painful knee locking caused by gouty tophi successfully treated with allopurinol." Nature Clinical Practice Rheumatology 4, no. 12 (2008): 675-679.