What are the treatment options for a gout flare?

Treatment Options for Gout Flare

For patients experiencing a gout flare, oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) are strongly recommended as first-line therapy. 1

First-Line Treatment Options

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum dose: 1.8 mg over a one-hour period 2
• Low-dose preferred: Low-dose colchicine is strongly recommended over high-dose due to similar efficacy with fewer adverse effects 1
• Contraindications:
  • Severe renal impairment
  • Patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors (e.g., cyclosporin, clarithromycin) 1
  • Dose adjustments required for patients with renal impairment 2

NSAIDs

• Equally effective as other first-line options 1
• Contraindications:
  • Renal disease
  • Heart failure
  • Cirrhosis 1
  • Should be avoided in patients with cardiovascular disease or heart failure 3

Glucocorticoids

• Options: Oral, intraarticular, or intramuscular administration 1
• Oral dosing: 30-35 mg/day of prednisolone equivalent for 3-5 days 1
• Advantages: Generally safer and lower cost compared to other options 1
• Best for: Patients who cannot take oral medications (NPO) should receive intramuscular, intravenous, or intraarticular glucocorticoids 1

Treatment Selection Algorithm

1. Assess patient for contraindications:

   • If renal impairment: Avoid NSAIDs and adjust colchicine dose; consider glucocorticoids
   • If cardiovascular disease/heart failure: Avoid NSAIDs; prefer colchicine or glucocorticoids 3
   • If on interacting medications: Check for P-glycoprotein/CYP3A4 inhibitors before using colchicine

2. Timing considerations:

   • Treat as early as possible after flare onset 1
   • Colchicine is most effective when given within 12 hours of flare onset 1

3. For patients who cannot tolerate first-line therapies:

   • Consider topical ice as an adjuvant treatment 1
   • IL-1 inhibitors may be considered in patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids, but are not recommended as first-line therapy 1

Prophylaxis During Urate-Lowering Therapy (ULT)

• Strongly recommended: Initiate prophylaxis when starting ULT to prevent flares 1
• Duration: Continue for 3-6 months after starting ULT 1
• Options:
  • Colchicine 0.5-1 mg/day (adjust for renal impairment) 1
  • Low-dose NSAIDs if colchicine is not tolerated or contraindicated 1

Important Clinical Considerations

• Early treatment: The most important determinant of therapeutic success is how soon therapy is initiated 4
• Urate-lowering therapy: When ULT is indicated, it can be conditionally started during a gout flare rather than waiting for resolution 1
• Lifestyle modifications: Recommend limiting alcohol intake, purine-rich foods, and high-fructose corn syrup; encourage weight loss in overweight/obese patients 1
• Medication adjustments: Consider switching hydrochlorothiazide to losartan when feasible, as losartan can help increase uric acid excretion 1, 5

Common Pitfalls to Avoid

1. Delaying treatment: Prompt treatment is crucial for effective management of gout flares
2. Inappropriate dosing: Using high-dose colchicine regimens increases adverse effects without improving efficacy
3. Failing to provide prophylaxis: Not providing prophylaxis when initiating ULT can lead to increased flare frequency
4. Overlooking comorbidities: Not considering cardiovascular disease, renal function, and other comorbidities when selecting treatment
5. Stopping ULT during flares: ULT should be continued during acute flares to maintain long-term urate control

By following these evidence-based recommendations, gout flares can be effectively managed while minimizing adverse effects and improving long-term outcomes for patients.