What is the workup and treatment for a first episode of gout during a flare?

From the Guidelines

The workup and treatment for a first episode of gout during a flare should focus on confirming the diagnosis and providing rapid symptom relief, with NSAIDs, colchicine, or oral corticosteroids as first-line treatment options, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The diagnosis of gout can be made through clinical presentation, serum uric acid levels, and joint aspiration to identify monosodium urate crystals under polarized microscopy. For acute treatment, the following options can be considered:

• NSAIDs such as naproxen 500mg twice daily or indomethacin 50mg three times daily for 5-7 days if there are no contraindications
• Colchicine with a loading dose of 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until the flare resolves
• Oral corticosteroids like prednisone 30-40mg daily for 3-5 days with a taper over 10-14 days for patients with contraindications to NSAIDs and colchicine Joint rest, ice application, and elevation can also help manage symptoms. After the acute flare resolves, it is essential to assess for underlying causes of hyperuricemia, such as diet, medications, and comorbidities. Long-term management may include urate-lowering therapy like allopurinol, particularly for patients with recurrent attacks, tophi, or chronic kidney disease, but this should be initiated only after the acute flare has resolved to avoid prolonging or worsening symptoms, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Additionally, lifestyle modifications, such as weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, can help reduce the risk of future gout attacks, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. It is crucial to note that the management of gout should be individualized, and the treatment plan should be tailored to the patient's specific needs and circumstances, as emphasized by the 2020 American College of Rheumatology guideline for the management of gout 1.

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. Workup and Treatment for a first episode of gout during a flare includes:

• Diagnosis: Confirming the diagnosis of gout
• Treatment:
  • Colchicine 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later 2
  • Monitoring for adverse effects of colchicine
• Dose Adjustment:
  • Consider dose adjustment in patients with renal or hepatic impairment 2
  • Consider alternate therapy in patients requiring repeated courses for the treatment of gout flares 2

From the Research

Workup for 1st Episode of Gout

• The diagnosis of gout is typically made based on the presence of monosodium urate crystals in the joint fluid, as well as clinical features such as hyperuricemia, acute monoarticular arthritis, and tophi 3.
• Imaging techniques, such as ultrasound and dual-energy computed tomography (CT), are also becoming increasingly important in the diagnosis of gout 4.
• Serum uric acid measurement is also a useful diagnostic tool, but it is not always elevated during an acute gout attack 3.

Treatment for 1st Episode of Gout

• The treatment of acute gout attacks focuses on nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and colchicine 4, 3.
• Colchicine is considered a safe and effective treatment for acute gout flares, especially in patients with cardiovascular disease or heart failure 5.
• Low-dose glucocorticoids are also efficacious and may be safe for short durations, but NSAIDs should be avoided in patients with cardiovascular disease or heart failure 5.
• The IL-1β antagonists, such as canakinumab, are highly effective for arresting flares, but their cost-effectiveness renders them salvage therapies 6.

Prevention of Future Gout Attacks

• Uric acid-lowering treatment with xanthine oxidase inhibitors, such as allopurinol, is an important part of long-term gout management 4, 6.
• Prophylaxis for flares induced by urate-lowering therapy is an important consideration in gout management, and low-dose colchicine and low-dose NSAIDs are recommended as first-line therapies 7.
• Lifestyle modifications, such as diet and exercise, can also help prevent future gout attacks 6.