What is the treatment for a gout (gouty arthritis) flare?

Treatment of Gout Flares

For acute gout flares, first-line treatment should be colchicine (within 12 hours of onset), NSAIDs, or oral corticosteroids, with the choice based on patient-specific factors including comorbidities, contraindications, and time of presentation. 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 1
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, etc.) 1, 2

NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses 1
• Examples: Naproxen (500 mg twice daily for 5 days), indomethacin 1
• Contraindications:
  • Severe renal impairment 1
  • History of peptic ulcer disease 3
  • Uncontrolled hypertension or heart failure 4, 3

Corticosteroids

• Oral: Prednisolone (30-35 mg/day for 3-5 days) 1
• Intra-articular: Direct injection into affected joint 1
• Intramuscular: Option for patients unable to take oral medications 1

Treatment Algorithm

1. Assess timing of flare:

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

2. Evaluate renal function:

   • Normal to moderate impairment: All options available
   • Severe impairment: Avoid colchicine and NSAIDs; use corticosteroids 1, 2

3. Consider cardiovascular status:

   • With cardiovascular disease: Colchicine preferred; avoid NSAIDs 4
   • With heart failure: Avoid NSAIDs; use colchicine or corticosteroids 4

4. For severe flares involving multiple joints:

   • Consider combination therapy (colchicine + NSAID or colchicine + corticosteroid) 1

Special Considerations

Elderly Patients

• Use caution with NSAIDs due to increased risk of adverse effects
• Consider corticosteroids as potentially safer option 3
• If using colchicine, consider lower doses due to decreased renal clearance 3

Treatment Failure

• If inadequate response to initial therapy (defined as <20% improvement in pain within 24 hours or <50% improvement at 24 hours) 1
• Consider switching to alternative first-line agent or combination therapy 1
• For patients with contraindications to all first-line options, IL-1 inhibitors may be considered 1

Adjunctive Therapy

• Topical ice application is recommended as an adjunct treatment 1
• Rest of the affected joint 5

Patient Education and Self-Management

Fully informed patients should be educated to self-medicate at the first warning symptoms ("pill in the pocket" approach) 1. This strategy is particularly important as early treatment leads to better outcomes.

Common Pitfalls to Avoid

1. Delaying treatment - Efficacy decreases with delayed initiation
2. Stopping urate-lowering therapy during flares - Continue ULT during acute attacks 1
3. Using inappropriate doses - High-dose colchicine regimens increase toxicity without improving efficacy 1
4. Neglecting prophylaxis - When starting ULT, prophylaxis should be continued for 3-6 months to prevent flares 1

By following these evidence-based recommendations, most gout flares can be effectively managed with minimal adverse effects, reducing morbidity and improving quality of life for patients with gout.