What is the best treatment for a gout flare-up?

Treatment of Gout Flare-Up

For acute gout flares, first-line treatment options include colchicine (within 12 hours of symptom onset), NSAIDs, or oral corticosteroids, with the choice depending on patient-specific factors such as comorbidities, contraindications, and timing of treatment initiation. 1

First-Line Treatment Options

Colchicine

• Dosing: 1 mg loading dose followed 1 hour later by 0.5 mg on day 1 1, 2
• Timing: Most effective when given within 12 hours of flare onset 1
• Advantages: Specific for gout inflammation
• Contraindications:
  • Severe renal impairment (GFR <30 mL/min)
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, etc.) 1, 2
• Common side effects: Gastrointestinal issues (diarrhea, nausea, vomiting) 1

NSAIDs

• Dosing: Various options (no evidence that indomethacin is superior to other NSAIDs) 1
• Example: Naproxen 500 mg twice daily for 5 days 1
• Contraindications:
  • Renal disease
  • Heart failure
  • Cirrhosis 1
• Consider: Adding proton pump inhibitor if GI risk factors present 1

Oral Corticosteroids

• Dosing: Prednisolone 30-35 mg daily for 3-5 days 1
• Advantages:
  • Similar efficacy to NSAIDs with fewer adverse effects
  • Generally safer and lower cost option for many patients 1
• Contraindications: Systemic fungal infections 1

Joint Aspiration and Injection

• Consider for monoarticular gout when other options are contraindicated
• Provides rapid relief while confirming diagnosis 1

Special Situations

Severe Renal Impairment

• Avoid: Colchicine and NSAIDs
• Preferred: Corticosteroids (oral or intra-articular) 1

Multiple Joint Involvement

• Consider combination therapy (e.g., colchicine plus NSAID or colchicine plus corticosteroid) 1

When First-Line Agents Fail or Are Contraindicated

• Consider: IL-1 inhibitors (though these are more expensive and less accessible) 1

Adjunctive Measures

• Topical ice application is recommended as an adjuvant treatment 1
• Rest the affected joint 3
• Educate patients on "pill in the pocket" approach for early self-treatment 1

Prevention of Future Flares

After treating the acute flare, consider:

1. Prophylaxis during initiation of urate-lowering therapy (ULT)

   • Colchicine 0.5-1 mg daily for 6 months 1
   • Adjust dose in renal impairment

2. Lifestyle modifications:

   • Weight loss if overweight
   • Avoid alcohol (especially beer and spirits)
   • Avoid sugar-sweetened drinks and foods rich in fructose
   • Limit intake of meat and seafood
   • Encourage low-fat dairy products 1

Common Pitfalls to Avoid

1. Delayed treatment: Early intervention is critical for best outcomes
2. Inappropriate colchicine dosing: High-dose colchicine regimens increase toxicity without improving efficacy 2
3. Failing to adjust medications for renal function: Particularly important with colchicine
4. Not considering drug interactions: Especially with colchicine and CYP3A4/P-gp inhibitors
5. Starting urate-lowering therapy during an acute flare: This can worsen symptoms

Remember that treating the acute flare is only the first step in gout management. For patients with recurrent flares, addressing the underlying hyperuricemia with urate-lowering therapy should be considered once the acute episode resolves.