What is the management approach for a gout flare?

Management of Acute Gout Flares

Acute gout flares should be treated as early as possible with colchicine, NSAIDs, or glucocorticoids as first-line therapy, with the specific choice based on patient factors and contraindications. 1

First-Line Treatment Options

Colchicine

• Dosing: 1 mg loading dose followed 1 hour later by 0.5 mg on day 1 1
• Timing: Most effective when given within 12 hours of symptom onset 1
• Contraindications:
  • Severe renal impairment (GFR <30 mL/min)
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, etc.) 1, 2
  • Low-dose colchicine is strongly preferred over high-dose due to similar efficacy with fewer adverse effects 1

NSAIDs

• Add proton pump inhibitor if appropriate 1
• Avoid in patients with severe renal impairment 1
• Example: Naproxen 500 mg twice daily for 5 days has shown equivalent efficacy to prednisolone 1

Glucocorticoids

• Oral: Prednisolone 30-35 mg daily for 3-5 days 1
• Intra-articular: Joint aspiration and injection of corticosteroids 1
• Particularly useful when oral medications cannot be taken 1

Adjunctive Therapy

• Topical ice application is conditionally recommended as an adjuvant treatment 1
• Rest of the affected joint 3

Special Situations

Patients Unable to Take Oral Medications

• Strongly recommend glucocorticoids (intramuscular, intravenous, or intra-articular) 1

When First-Line Agents Are Contraindicated or Ineffective

• IL-1 inhibitors may be considered 1
• Note: Current infection is a contraindication to IL-1 inhibitors 1

Patients with Severe Renal Impairment

• Avoid colchicine and NSAIDs 1
• Consider glucocorticoids as preferred option
• If colchicine must be used in severe renal impairment:
  • Treatment course should not be repeated more than once every two weeks 2
  • For dialysis patients, reduce to a single dose of 0.6 mg 2
  • Recent evidence suggests reduced doses (≤0.5 mg/day) may be effective and well-tolerated in severe CKD, though this remains off-label 4

Patient Education and Self-Management

• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 1
• Early treatment leads to better effectiveness 1

Prevention of Recurrent Flares

Prophylaxis During Urate-Lowering Therapy (ULT)

• Recommended during first 6 months of ULT 1
• Options:
  • Colchicine 0.5-1 mg/day (reduce dose in renal impairment) 1, 5
  • Low-dose NSAIDs if colchicine is not tolerated 1

Lifestyle Modifications

• Weight loss if overweight/obese 1
• Limit alcohol intake, especially beer and spirits 1
• Avoid sugar-sweetened drinks and foods rich in fructose 1
• Limit purine-rich foods (organ meats, shellfish) 1, 6
• Encourage low-fat dairy products 1
• Regular exercise 1

Common Pitfalls to Avoid

1. Delaying treatment - efficacy decreases significantly when treatment is delayed
2. Using high-dose colchicine regimens - low-dose is equally effective with fewer side effects
3. Failing to adjust medication doses in renal impairment
4. Not providing prophylaxis when initiating urate-lowering therapy
5. Continuing diuretics that can worsen hyperuricemia - consider losartan as an alternative antihypertensive when possible 1, 6

The management of gout flares requires prompt intervention with appropriate anti-inflammatory medications, with careful consideration of patient comorbidities, particularly renal function, when selecting therapy.