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OBJECTIVE: Currently available guidelines on urate-lowering therapy (ULT) initiation in acute gout flare are conflicting. We compared the time to complete resolution of acute gout flare between early and late allopurinol initiation. METHODS: This 28-day, randomized controlled, open-label trial included patients with crystal-proven gout who were presented with acute gout flare within 72 h of arthritis onset. Exclusion criteria were advanced renal failure, ongoing ULT, and presence of the HLA-B*5801 allele. Allopurinol was used on days 1 and 14 in early and late groups, respectively. Primary outcome was time to complete arthritis resolution, and secondary outcomes were time to clinical resolution; arthritis relapse; laboratory parameters; and adverse events. RESULTS: One hundred seventeen patients were randomized to early and late allopurinol groups (n = 59 and 58, respectively). One patient in each group was lost to follow-up; therefore, 115 patients were included in the modified intention-to-treat analysis. Baseline characteristics were comparable between the groups. The median time to complete resolution was not significantly different between the early and late allopurinol groups (6 [5-14] and 6 [5-7] days, respectively; p = 0.14). The median time to clinical resolution was 4 [3-6] days in both groups (p = 0.12). Other secondary outcomes were not significantly different. Serious adverse events did not occur in either group. CONCLUSIONS: Early allopurinol initiation during an acute gout flare did not lead to significant changes in time to resolution, flare recurrence, and inflammatory markers. Key Points • Allopurinol Initiation in Gout.