What is the recommended treatment for an acute gout flare?

Treatment for Acute Gout Flare

First-line treatment options for acute gout flares include colchicine (within 12 hours of flare onset), NSAIDs, or oral corticosteroids, with the choice based on patient-specific factors such as timing of treatment, comorbidities, and contraindications. 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
• Timing: Most effective when given within 12 hours of symptom onset 1
• Contraindications:
  • Severe renal impairment
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (e.g., cyclosporin, clarithromycin)
  • Hepatic impairment

NSAIDs

• Dosing: Use maximum recommended doses for short duration
• Examples: Naproxen (500 mg twice daily for 5 days), indomethacin, ibuprofen
• Contraindications:
  • Renal disease
  • Heart failure
  • Cirrhosis
  • History of gastrointestinal bleeding
• Note: No evidence that indomethacin is more effective than other NSAIDs 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: Generally safer and lower cost than other options 1
• Contraindications:
  • Systemic fungal infections
  • Uncontrolled diabetes
  • Active infection

Treatment Selection Algorithm

1. Assess timing from symptom onset:

   • If <12 hours: Consider colchicine as preferred option
   • If >12 hours: NSAIDs or corticosteroids may be more effective

2. Assess renal function:

   • If severe renal impairment: Avoid colchicine and NSAIDs; use corticosteroids
   • If moderate renal impairment: Avoid NSAIDs; consider dose-adjusted colchicine or corticosteroids

3. Assess cardiovascular risk:

   • If high CV risk or heart failure: Avoid NSAIDs; prefer corticosteroids or colchicine 3

4. Assess GI risk:

   • If history of GI bleeding or ulcers: Avoid NSAIDs; use corticosteroids or colchicine
   • If using NSAIDs: Consider adding PPI for gastroprotection 1

5. For severe, polyarticular flares:

   • Consider combination therapy (e.g., colchicine plus corticosteroids) 1
   • Consider joint aspiration and injection of corticosteroids for monoarticular gout 1

Additional Treatment Options

For patients with contraindications to all first-line therapies:

• IL-1 inhibitors (e.g., anakinra, canakinumab) may be considered 1, 4
  • More expensive than traditional options
  • Contraindicated in active infection

Common Pitfalls and Caveats

1. Delayed treatment: Early intervention is crucial for optimal response. Educate patients to self-medicate at first warning symptoms ("pill in pocket" approach) 1

2. Incorrect colchicine dosing: High-dose colchicine regimens increase adverse effects without improving efficacy 1

3. Initiating urate-lowering therapy during acute flare: This can worsen or prolong the flare; focus on anti-inflammatory treatment first

4. Overlooking prophylaxis: When starting urate-lowering therapy after flare resolution, provide prophylaxis with colchicine 0.5-1 mg daily or low-dose NSAIDs for 6 months 1

5. Failing to address lifestyle factors: Advise patients to avoid alcohol (especially beer), sugar-sweetened drinks, and purine-rich foods (organ meats, shellfish) 1, 5

By following this evidence-based approach to treating acute gout flares, you can effectively manage pain and inflammation while minimizing adverse effects based on individual patient factors.