What is the recommended treatment for an acute gout flare?

From the Guidelines

The recommended treatment for an acute gout flare includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids, which should be started as soon as possible after symptom onset, as stated in the 2017 updated EULAR evidence-based recommendations for the management of gout 1.

Treatment Options

• First-line options include NSAIDs such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 5-7 days.
• Alternatively, colchicine can be used at a dose of 1 mg followed 1 hour later by 0.5 mg on day 1, as recommended by the 2017 EULAR guidelines 1.
• For patients who cannot take NSAIDs or colchicine, oral prednisone (30-40mg daily for 3-5 days, followed by a taper) or intra-articular corticosteroid injections are effective options.

Important Considerations

• 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 outlined in the 2017 EULAR guidelines 1.
• Urate-lowering therapy should not be initiated or discontinued during an acute flare as this can worsen symptoms, as noted in the 2012 American College of Rheumatology guidelines 1.
• Adequate hydration is important, and the affected joint should be rested, elevated, and ice may be applied for additional pain relief.

Lifestyle Modifications

• Patients with gout should receive advice regarding lifestyle modifications, including weight loss if appropriate, avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals, and excessive intake of meat and seafood, as recommended by the 2017 EULAR guidelines 1.
• Low-fat dairy products should be encouraged, and regular exercise should be advised.

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 an acute gout flare is 1.2 mg of colchicine at the first sign of the flare, followed by 0.6 mg one hour later.

• The dose should not exceed 1.8 mg over a one hour period.
• If the patient is undergoing dialysis, the recommended dose is 0.6 mg (one tablet), and the treatment course should not be repeated more than once every two weeks 2.
• For patients with severe renal impairment, the treatment course should be repeated no more than once every two weeks 2.
• For patients with severe hepatic impairment, the treatment course should be repeated no more than once every two weeks 2.

From the Research

Treatment Options for Acute Gout Flare

The treatment of acute gout flare focuses on several key options, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5
• Glucocorticoids 3, 6, 5
• Colchicine 3, 6, 5
• Interleukin-1 inhibitors, such as canakinumab and rilonacept 6

Comparison of Treatment Options

Studies have compared the effectiveness of these treatment options:

• Canakinumab was found to be probably superior to triamcinolone acetonide in terms of pain relief, resolution of joint swelling, and participant-assessed global assessment of treatment response, but was associated with an increased risk of adverse events 6
• NSAIDs were found to be effective in reducing pain and improving function, but may have little to no effect on inflammation and adverse events 4
• COX-2 inhibitors (COXIBs) and non-selective NSAIDs were found to be probably equally beneficial in terms of improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 4
• Systemic glucocorticoids and NSAIDs were found to be probably equally beneficial in terms of pain relief, improvement in function, and treatment success, although NSAIDs probably result in more total adverse events 4

Recommendations for Treatment

Based on the available evidence, the recommended treatment for acute gout flare includes:

• NSAIDs, glucocorticoids, and colchicine as first-line treatments 3, 5
• Interleukin-1 inhibitors, such as canakinumab, as an alternative option for patients who do not respond to first-line treatments 6
• Xanthine oxidase inhibitors (XOI) or uricosuric drugs for patients with recurrent or severe gout 5
• Comprehensive patient education and counseling, as well as regular laboratory follow-up, are important components of treatment 5