What is the recommended treatment for a gout flare?

From the Guidelines

The recommended treatment for a gout flare includes starting an anti-inflammatory medication as soon as possible, with first-line options being colchicine, NSAIDs, or oral corticosteroids. According to the 2020 American College of Rheumatology guideline for the management of gout 1, colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) are strongly recommended for managing gout flares. The choice of drug(s) should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved, as stated in the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

Some key points to consider when treating a gout flare include:

• Starting treatment within the first 24 hours of symptom onset for maximum effectiveness
• Using colchicine, typically given as 1.2mg immediately, followed by 0.6mg one hour later, then 0.6mg once or twice daily until the flare resolves
• Using NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 5-7 days
• Using oral corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) for patients who cannot take NSAIDs or colchicine
• Resting the affected joint, applying ice for 20-minute periods several times daily to reduce pain and swelling, and staying well-hydrated during a flare
• Continuing any medication that lowers uric acid levels (like allopurinol) if already prescribed, but not starting it during an acute attack, as recommended by the American College of Physicians guideline on management of acute and recurrent gout 1.

It's essential to note that the goal of treatment is to reduce inflammation caused by uric acid crystal deposits in the joints, which trigger the intense pain, redness, and swelling characteristic of gout flares. The 2020 American College of Rheumatology guideline for the management of gout 1 provides strong recommendations for the management of gout flares, and the 2016 updated EULAR evidence-based recommendations for the management of gout 1 offer guidance on the choice of drug(s) and treatment approach.

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. The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period.

The recommended treatment for a gout flare is:

• Colchicine: 1.2 mg (two tablets) at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later.
• Maximum dose: 1.8 mg over a one hour period.
• Repeat treatment: may be administered for treatment of a gout flare during prophylaxis at doses not to exceed 1.2 mg (two tablets) at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later. Wait 12 hours and then resume the prophylactic dose. 2

From the Research

Gout Flare Treatment Options

• The recommended treatment for a gout flare includes standard pharmacotherapies such as colchicine, NSAIDs, and oral or intramuscular corticosteroids 3.
• IL-1 inhibitors are also newly established as an option for flare refractory to standard therapies 3.
• Other treatment options include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 4, 5, 6
  • Corticosteroids 4, 5, 6
  • Colchicine 4, 5, 6
  • Interleukin-1 (IL-1) inhibitors, such as canakinumab 5, 6
  • Adrenocorticotropic hormone (ACTH) 5
  • Topical ice 5
  • Herbal supplements 5

Treatment Considerations

• The choice of treatment should be based on the individual patient's needs and comorbidities, such as chronic kidney disease and ischemic heart disease 3.
• Patient preference should also be taken into account when selecting a treatment option 3.
• Comprehensive patient education and counseling is an important component of the treatment of patients with gout 4.
• Regular laboratory follow-up is necessary to monitor the patient's condition and adjust treatment as needed 4.

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 3.
• Initial treatments include allopurinol and febuxostat, with uricosuric agents, probenecid, sulfinpyrazone, and benzbromarone, as adjuncts 3.
• The target uric acid value is <6 mg/dL 4.