From the Guidelines
The most effective treatment approach for an acute gout flare is to use colchicine, NSAIDs, or oral corticosteroids as first-line options, with the choice of drug based on the presence of contraindications, patient's previous experience, and the number and type of joints involved. According to the 2016 updated EULAR evidence-based recommendations for the management of gout 1, acute flares of gout should be treated as early as possible, and fully informed patients should be educated to self-medicate at the first warning symptoms. The recommended first-line options for acute flares are colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) or articular aspiration and injection of corticosteroids.
Some key points to consider when treating acute gout flares include:
- Colchicine and NSAIDs should be avoided in patients with severe renal impairment 1
- Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1
- In patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroid, IL-1 blockers should be considered for treating flares 1
- Current infection is a contraindication to the use of IL-1 blockers 1
The American College of Physicians also recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout, with a strong recommendation and high-quality evidence 2. Additionally, low-dose colchicine is recommended when using colchicine to treat acute gout, with a strong recommendation and moderate-quality evidence 2.
It's essential to start treatment as early as possible after symptom onset, as this significantly improves outcomes. These medications work by inhibiting inflammatory pathways triggered by urate crystal deposition in the joints, which causes the characteristic severe pain, redness, and swelling of gout attacks. During treatment, the affected joint should be rested, elevated, and ice can be applied to reduce pain and swelling. Adequate hydration is important to help eliminate uric acid. Patients should temporarily avoid alcohol and purine-rich foods during the flare.
From the FDA Drug Label
The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. Higher doses have not been found to be more effective. The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period.
The treatment approach for an acute gout flare is to administer 1.2 mg of colchicine at the first sign of the flare, followed by 0.6 mg one hour later.
- The maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period.
- Higher doses have not been found to be more effective.
- This treatment approach is based on the information provided in the drug label for colchicine (PO) 3.
From the Research
Treatment Approach for Acute Gout Flare
The treatment approach for acute gout flare typically involves the use of pharmacotherapies to manage pain and inflammation.
- Standard pharmacotherapies for gout flares include: + Colchicine + Nonsteroidal anti-inflammatory drugs (NSAIDs) + Oral or intramuscular corticosteroids + IL-1 inhibitors for flare refractory to standard therapies 4
- Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout, with low-certainty evidence suggesting that NSAIDs may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events 5
- Moderate-certainty evidence shows that COXIBs and non-selective NSAIDs are probably equally beneficial with regards to improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 5
- Moderate-certainty evidence also shows that systemic glucocorticoids and NSAIDs probably are equally beneficial in terms of pain relief, improvement in function, and treatment success 5
- Other treatment options, such as colchicine and IL-1 inhibitors, may also be effective in treating acute gout, with moderate quality evidence concluding that systemic glucocorticoids were as effective as NSAID but safer, and low quality evidence showing that both high- and low-dose colchicine were more effective than placebo 6
Urate-Lowering Therapies
Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy; the escalation of therapies until the target serum uric acid is reached.
- Initial treatments include allopurinol and febuxostat, with uricosuric agents, probenecid, sulfinpyrazone and benzbromarone, as adjuncts 4
- The use of prophylactic agents, such as NSAIDs and colchicine, may be necessary to prevent gouty flare when beginning urate-lowering therapy 7
Emerging Therapies
There are also emerging therapies in development for the treatment of acute gout, including new pharmacotherapies and treatment approaches 4, 8
- A network meta-analysis is being conducted to systematically compare non-steroidal anti-inflammatory drugs (NSAIDs), COXIBs, colchicine, hormones, or IL-1 receptor antagonists, etc. for acute gout based on the latest evidence 8