What is the initial management for gout flare symptoms?

From the Guidelines

The initial management of gout flare symptoms should involve prompt use of anti-inflammatory medications, with first-line options including colchicine, NSAIDs, or corticosteroids, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The choice of medication should be based on the presence of contraindications, the patient's previous experience with treatments, and the number and type of joints involved, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Some key points to consider in the management of gout flare symptoms include:

• Starting treatment as early as possible, ideally within 12 hours of flare onset, with a loading dose of colchicine (1 mg) followed by 0.5 mg one hour later, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
• Using NSAIDs, such as naproxen or indomethacin, at a dose of 500mg twice daily or 50mg three times daily for 3-5 days, as suggested by the example answer
• Considering corticosteroids, such as prednisone, at a dose of 30-40mg daily for 3-5 days with a taper, as recommended by the example answer
• Maintaining adequate hydration, resting the affected joint, and applying ice for 20 minutes several times daily to reduce pain and inflammation
• Avoiding alcohol and purine-rich foods during the flare, as recommended by the example answer
• Continuing usual urate-lowering therapy, if already prescribed, during the flare, as stopping it can worsen symptoms, as suggested by the example answer. It is essential to note that the management of gout flare symptoms should be individualized, taking into account the patient's medical history, comorbidities, and previous response to treatment, as recommended 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. The initial management for gout flare symptoms is to take 1.2 mg of colchicine at the first sign of the flare, followed by 0.6 mg one hour later 2.

• The maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period.
• For patients with severe renal impairment, the dose does not need to be adjusted for the treatment of gout flares, but a treatment course should be repeated no more than once every two weeks.
• For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet) 2.

From the Research

Initial Management for Gout Flare Symptoms

The initial management for gout flare symptoms typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine 3, 4, 5.

• NSAIDs are commonly used to treat acute gout flares, but their use should be avoided in patients with cardiovascular disease or heart failure 4.
• Corticosteroids can be used to treat acute gout flares, especially in patients who cannot tolerate NSAIDs or colchicine 3, 4.
• Colchicine is considered safe and potentially reduces the risk of myocardial infarction in patients with cardiovascular disease or heart failure 4.

Alternative Treatment Options

In some cases, alternative treatment options may be considered, such as:

• Interleukin-1 inhibitors (e.g., anakinra, canakinumab) for acute gout flares 6, 7.
• Urate-lowering therapy (ULT) to reduce uric acid levels and prevent recurrent gout flares 3, 4.

Important Considerations

When managing gout flare symptoms, it is essential to consider the following:

• The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 3.
• Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 3.